University of Groningen The dark side of p-phenylenediamine Vogel, Tatiana Alexandra IMPORTANT NOTE: You are advised to consult the publisher's version (publisher'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 publication in University of Groningen/UMCG research database Citation for published version (APA): Vogel, T. A. (2016). The dark side of p-phenylenediamine: Biological aspects and prevalence of contact allergy to an extraordinary molecule [Groningen]: Rijksuniversiteit Groningen Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date: 02-11-2018
Chapter 8 Allergic contact dermatitis persisting as severe and persistent blepharoconjunctivitis and centrofacial oedema after dyeing of eyelashes Tatiana A. Vogel, Pieter-Jan Coenraads and Marie-Louise A. Schuttelaar Dermatology, University Medical Center Groningen, Department of Dermatology, 9700 RB Groningen, The Netherlands Published in Contact Dermatitis 2014; 71; 303-306 0
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8. Blepharoconjunctivitis caused by PPD Introduction p-phenylenediamine (PPD) is a hapten with an extreme sensitizing potency. It is responsible for contact allergies in 4% of the European patch tested population. In this report, we describe a case of a 34-year-old woman with a severe and persistent blepharoconjunctivitis accompanied with centrofacial oedema, caused by a contact allergy to PPD, present in eyelash dye. Case history A 34-year-old, healthy, non-atopic, Caucasian woman presented to us with oedema and redness of both eyelids. This dermatitis appeared 2 days after her eyelashes were dyed with a permanent black eyelash dye (Babor Eyelash Tint containing PPD) by a beautician. Progression of her dermatitis was still ongoing 14 days after initiation and, despite oral treatment with prednisone 20mg daily, persisted for 6 weeks. The patient had never used any hair dye products. However, in the past, she had experienced an itchy rash after having a temporary black henna tattoo while on holiday. Dermatological examination showed oedema and erythema of the cheeks, the forehead and the perioculair region. Moreover, severe conjunctival hyperaemia and a mild chemosis with mucous discharge was seen (Figure 1). Figure 1: A: Oedema and erythema of the cheeks, the forehead, and the perioculair region. B, C: Conjunctival hyperaemia and mild chemosis with mucus discharge of both eyes, with perioculair oedema and some erosions. Pictures printed with full consent of the patient. 107
This blepharoconjunctivitis with centrofacial oedema was clinically suspected of being caused by a contact allergy to one of the eyelash dye components. Therefore, patch tests with our extended European Baseline Series (TRUE Test, Mekos Laboratories AS, Hillerød, Denmark) and a hairdressers series (Chemotechnique, Vellinge, Sweden) were performed, after the dermatitis was in remission and prednisone treatment had been tapered off. The tests were read according to ICDRG criteria on D3 and D7 after application, with an additional reading being performed on D1. The patient showed a strong positive reaction (++) to PPD 0.5% pet. on D1, after which this patch was removed. On D3 and D7, multiple positive reactions were seen to substances known for their cross-reactivity with PPD (Table 1). Moreover, she showed positive reactions to carba-mix (++), colophonium (++) and p-tert-butylfenol formaldehyde resin (+), which were classified as not relevant in this case. Patient was strongly advised to avoid contact with products containing PPD, in order to prevent such a reaction in the future. Test results D1 D3 D7 p-phenylene diamine dihydrochloride 0.5% pet. ++ +++ ++ Caine mix (630 µg/cm 2 ) NR ++ + Black rubber mix (75µg/cm 2 ) NR ++ + Diaminotoluene sulfaat 1% pet. NR +++ + o-nitro-p-phenylenediamine 1% pet. NR +++ + p-aminophenol 1% pet. NR +++ + m-aminophenol 1% pet. NR ++ + Hydroquinone NR ++ + Table 1: The relevant results of the patch tests. Readings according to the criteria of the International Contact Dermatitis Research Group on D3 and D7, with an additional reading of p-phenylenediamine on D1, because of the severe dermatitis after exposure to the eyelash dye. NR, not read. Discussion We have described a case of a young woman with a severe and persistent contact allergic reaction to PPD, with blepharoconjunctivitis and centrofacial oedema. Allergic contact reactions to PPD are common, and black henna tattoos constitute a well-known cause of sensitization. However, this is, to the best of our knowledge, the first case of such severe and persistent contact allergy to PPD in eyelash dye after previous sensitization by a black henna tattoo. 108
8. Blepharoconjunctivitis caused by PPD PPD present in hair dyes is one of the main causes of contact allergy to PPD. However, an important group of sensitizers are the black henna tattoos. 1,2 This temporary skin art is offered to tourists, including young children, in non-european countries around the Mediterranean. In these countries the presence of PPD in these henna tattoos is not illegal, and therefore concentrations up to 30% are seen in the final product. 3 In 1966, it was demonstrated by Kligman et al. that 100% of the 24 tested inmates became sensitized after having been exposed to a concentration of 10% PPD. 4 Moreover, solvents and mineral oils present in black henna enhance penetration of, and therefore sensitization to, PPD. It is interesting that the elicitation reaction in this young woman was very severe. Previous studies have shown that sensitization with a higher dose of the allergen causes more extreme elicitation reactions. 5-7 Although these studies were not performed with PPD, one could presume that this same phenomenon could be applicable to sensitization to PPD, as in our patient. This makes the use of black henna, containing high concentrations of PPD, a highrisk activity. 8,9 A second noteworthy aspect of this case is the duration of the patient s complaints after dyeing of her eyelashes. It was striking that the allergic reaction persisted for 6 weeks after dyeing, despite treatment with prednisone up to 20 mg daily. This dose of prednisone might have been insufficient to treat the dermatitis. Anveden et al. have reported that oral treatment with prednisone 20 mg only partly suppresses patch test reactivity. This suggests that the dose of prednisone should have been higher to completely suppress the elicitation reaction. 10 In the current case, this is the most likely explanation for the persistence of the complaint. In summary, we have presented a case of severe persistent blepharoconjunctivitis caused by PPD in permanent eyelash dye. This case emphasizes the risk of so-called temporary black henna tattoos, which usually contain extremely high concentrations of PPD. Sensitization can be accompanied by severe and persistent elicitation reactions, which should be treated with high doses of prednisone. 109
Literature 1 de Groot AC. Side-effects of henna and semi-permanent black henna tattoos: a full review. Contact Dermatitis 2013; 69:1-25. 2 Kind F, Scherer K, Bircher AJ. Contact dermatitis to para-phenylenediamine in hair dye following sensitization to black henna tattoos - an ongoing problem. J Dtsch Dermatol Ges 2012; 10:572-8. 3 Schnuch A, Lessmann H, Frosch PJ, Uter W. para-phenylenediamine: the profile of an important allergen. Results of the IVDK. Br J Dermatol 2008; 159:379-86. 4 Kligman AM. The identification of contact allergens by human assay. 3. The maximization test: a procedure for screening and rating contact sensitizers. J Invest Dermatol 1966; 47:393-409. 5 Friedmann PS, Pickard C. Quantifying human susceptibility to contact sensitization; risk assessments now and in the future. Contact Dermatitis 2010; 63:237-47. 6 6 Friedmann PS. The relationships between exposure dose and response in induction and elicitation of contact hypersensitivity in humans. Br J Dermatol 2007; 157:1093-102. 7 Nakamura Y, Higaki T, Kato H, et al. A quantitative comparison of induction and challenge concentrations inducing a 50% positive response in three skin sensitization tests; the guinea pig maximization test, adjuvant and patch test and Buehler test. J Toxicol Sci 1999; 24:123-31. 8 Corrente S, Moschese V, Chianca M, et al. Temporary henna tattoo is unsafe in atopic children. Acta Paediatr 2007; 96:469-71. 9 Matulich J, Sullivan J. A temporary henna tattoo causing hair and clothing dye allergy. Contact Dermatitis 2005; 53:33-6. Anveden I, Lindberg M, Andersen KE, et al. Oral prednisone suppresses allergic but not irritant patch test 10 reactions in individuals hypersensitive to nickel. Contact Dermatitis 2004; 50:298-303. 110