Pre-testing in hair dye users: an assessment of the Colourstart™ system

ARTICLE

Auteur(s) : David A Basketter¹, John English²

¹DABMEB Consultancy, Sharnbrook, Bedfordshire, UK
²Department of Dermatology, Nottingham University Hospital, Nottingham, UK

accepté le 1 Janvier 2009

Consumer and occupational exposure to skin sensitising ingredients contained in nearly all hair dyes has long been associated with a history of allergic contact dermatitis (ACD) [1-4]. The primary culprit in this respect has been recognised for many years to be p-phenylenediamine (PPD), although precise details of its chemical mechanism of sensitisation remain the subject of investigation [2, 4, 5]. Through its routine use in almost all standard patch test batteries, the frequency with which it gives rise to a positive patch test in consecutive patients has been described in many countries [6-9]. How this translates into a frequency of allergy in the general adult population is a matter of inexact extrapolation, but seems likely to be in the order of 1%-3%. Whilst a good proportion of these individuals, for a variety of reasons, may not express ACD when exposed to PPD during hair dyeing, it is evident that a significant number do suffer from hair dye elicited eczema [10-12]. Furthermore, a modest proportion of them experience adverse reactions to a degree that is beyond a mild itchy rash, but rather is a more serious eczema and is sometimes associated with a substantial degree of oedema, particularly of the face and hand, often requiring a period of hospitalisation [12-16].

The manufacturers of hair dyes have long recognised that their products can cause allergy and whilst they might contest the details of the frequency with which this occurs, for decades they have recommended the use of a skin sensitivity test prior to each use of hair dye. It is not the purpose of this paper to debate the appropriateness of this recommendation. Rather it is to address whether one particular approach has the potential to work in practice. At present, there is no standardised system in place. One major manufacturer has published details of how it considers sensitivity testing should be undertaken and completed a study in PPD allergic volunteers to demonstrate its utility [17, 18]. However, as far as the present authors are aware, the use of this method in hair dyeing salons, at least in the UK, is very low (probably < 10%). One reason for this is perhaps that the technical aspects of using a poorly defined “blob” of an active hair dye mix behind the ear (applied × 3 and dried), 2 days before hair dyeing are relatively complex for the consumer and/or for hairdressing salon staff. The Colourstart™ system is a simple rub on transfer, applied with the use of a little water to wet it (figure 1), where ease of use is likely to contribute substantially to compliance. Recently, however, a small clinical study cast doubt on whether Colourstart™ would in reality identify much more than half of those at significant risk of a serious adverse reaction to hair dyes [19]. Consequently, in this present work, we designed a more structured study to investigate whether and to what extent the low dose of PPD in the Colourstart™ system would be able to detect sensitivity to PPD in a panel of volunteers with a previous full clinical diagnosis of PPD allergy. Further, to gauge more accurately the practical utility of Colourstart™, groups of 10 patients who had shown 3+, 2+ or 1+ diagnostic patch test reactivity were assessed using Colourstart™ applied according to the manufacturer’s instructions. This study cannot inform directly on the performance of this product in hair dye salon customers, but unless it can be shown to perform adequately in individuals already known to be sensitised, then its practical utility would be open to reasonable challenge. It should be noted that there is no intention here to suggest that the system provides an alternate diagnostic tool; the purpose is to try to gauge the extent to which Colourstart™ has the capacity to provide an alert of a potential problem prior to hair dyeing in a salon.

Materials and methods

Subjects

Materials

Protocol

Results

It is interesting to note that of the 3+ diagnostic patch test reactors, 90% gave either a +++ or a ++ reaction to Colourstart™. Among the 2+ patch test reactors, of the 8 who reacted to Colourstart™, the reactions were generally weaker, with only a single +++ response, whereas 5 gave a + response. The lone 1+ diagnostic patch test reactor who reacted to Colourstart™ also reacted only at the 1+ level to Colourstart™.

None of the subjects reported back to the hospital with strengthening delayed reactions to Colourstart™ after the 48 h scoring point.
Table 2 Results of testing Colourstart™ in 30 PPD allergic subjects

Discussion

Colourstart™ is a skin transfer which contains a small amount of PPD in a hexagonal shape at a dose of 30 μg/cm². It offers a standardised approach to the identification of individuals with PPD sensitivity via its ease of use and relatively long shelf life. What must be ensured however is that the system functions properly, i.e. that it identifies those with a substantial, potentially problematical degree of PPD allergy. It is already known that PPD allergic individuals whose degree of reactivity is relatively low can generally tolerate exposure and can continue to dye their hair [26]. Of course, this may not be a wise strategy since further exposure risks increasing their reactivity. Such individuals contrast with those who have a greater degree of sensitivity to PPD (giving a 2+ reaction to the diagnostic patch test), of whom only about half say they could continue to dye their hair, and even more so with the most sensitive individuals (those giving a 3+ reaction to the diagnostic patch test), who universally indicate that they can no longer tolerate hair dye exposure [26]. Consequently, a system such as Colourstart™, to be regarded as appropriately functional, must identify all of those who were 3+ and ideally all of those who were2+; identification of 1+ reactors might be regarded as more optional. The results presented here indicate that this is very much how Colourstart™ performed, with all 3+ reactors being picked up as well as 80% of the 2+ reactors. The analysis carried out by Ho and colleagues shows that these are the individuals most at risk of a significant adverse reaction [26]. It is of note that a single 2+ individual who had experienced a severe hair dye reaction was negative to Colourstart™. In the light of the response of the remainder of the test group, one is left to speculate whether in this individual, the hair dye chemical responsible for the severity of her reaction was a material other than PPD and which also does not cross react with it. Consistent with this, the subject was negative on previous patch testing to other hair dyes which normally cross react with PPD, her only other contact allergy being to nickel. Inevitably, a weakness of any system based only on PPD will be that it will not identify sensitivity to hair dye chemicals which are neither PPD nor at least substances that cross react with it well.

The above results with Colourstart™ are at first sight not fully consistent with the recent data reported by Orton, who found that only 3/7 PPD allergic patients responded to Colourstart™. Whilst this overall rate of positivity (43%) is not dramatically different to that of the present study (63%), it is important to examine the patient group involved. In this earlier study, all of the 3+ PPD positives in the diagnostic patch test were also positive to Colourstart™ (although in one case the reaction was weak), a result fully consistent with the present work. Furthermore, all of those (3/3) who were 1+ reactors in the PPD diagnostic patch test were negative to Colourstart, again a result very much consistent with the present observations. This leaves only a single 2+ reactor, who was negative to Colourstart™ in the Orton study; this represents in reality the only real discrepancy. Since in our hands, Colourstart was positive in 80% of 2+ reactors, then the individual in the Orton study could by chance just be one of the “weaker” 2+ diagnostic patch test reactors, a view given credence by their reaction to 1% PPD in petrolatum being 2+ only at 48h and just 1+ at the 96h scoring point.

To identify more of the 1+ reactors (Colourstart™ only identified 10%) would require higher exposure to PPD, which may well be inappropriate, as this must increase the risk of induction of allergy. This might well be argued to be an inappropriate strategy for self test systems such as Colourstart™. As noted in a recent editorial: “A safe, sensitive and reproducible screening self-test would be a welcome tool to prevent severe allergic reactions to hair dye.” [24]. The present work provides a key part of the evidence that this is what Colourstart™ might deliver. The editorial also raises a number of other very pertinent questions, not the least of which is the need for training/guidance of those using self test systems. This might include not only the use and interpretation of the test, but also suitable commentary on its accuracy. Clearly, Colourstart™ is unlikely (by design?) to detect those with only a weak contact allergy to PPD. Furthermore, although it is likely also to detect those individuals with allergy to hair dye chemicals closely related to, and which are known to cross react with, PPD, it will not identify sensitivity to non-PPD related hair dye allergens. For example, although there is considerable cross reaction between PPD and PTD, occasional isolated allergy to PTD is observed [27] and this probably is the explanation for the failure of Colourstart™ to identify the lone PTD allergic individual in the Orton study [19].

Acknowledgements

References

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