Hairdressers’ dermatologic odyssey: From dye to death prevention

 

By Warren R. Heymann, MD
Dec. 18, 2017

My younger daughter Deborah was destined to be a hair stylist. When she was a camper in the Poconos, I received an urgent call from the staff about her. Assuming the worst, my heart palpitating in fear, all I could do was laugh when I was informed that she violated camp policy by dyeing her hair. “Dr. Heymann, What do you want me to tell your daughter?” the camp administrator inquired. “Please tell her to choose a good color!”

Now that she is a professional cosmetologist with a specialty in hair coloring, I have a heightened interest in the occupational hazards of the profession.

I was very impressed with the training that my daughter received getting in her cosmetology degree to qualify for licensure — she had to learn quite a bit of chemistry and biology. I was especially pleased with her tutorial on recognizing skin disease, including melanoma and non-melanoma skin cancer.

Hairdressing is wet work because of hand and hair washing. Exposure to potential irritant and allergens including dyes, bleach, permanent wave chemicals, preservatives, fragrances, rubber products and metals (nickel).

A cohort study of all hairdressers with recognized occupational contact dermatitis in Denmark from January 2006 to September 2011 was performed. It included 381 patients (373 women and 8 men). The median age was 25 years, 64.8% were apprentices, and 35.2% were fully trained hairdressers. The prevalence of atopic dermatitis was 36.0%, and was significantly higher among apprentices than among fully trained hairdressers (44.9% and 19.4%, respectively) (p < 0.001); 48.3% had their dermatitis recognized as occupational irritant contact dermatitis, 46.7% as occupational allergic contact dermatitis or combined allergic and irritant contact dermatitis, and 5.0% were diagnosed with occupational contact urticaria. The significant difference in the prevalence of atopic dermatitis between apprentices and fully trained hairdressers had not been previously reported. This finding supported the idea that atopic dermatitis significantly influences the development of hand eczema, which could significantly influence the decision to change careers. The authors stressed the importance of prevention at an early stage of apprenticeship. (1) How can this be accomplished?

Oxidative hair dyes are still among the most common causes of occupational contact allergy among hairdressers. (2) The gold standard of diagnosing allergic contact dermatitis is via epicutaneous patch testing. p-Phenylenediamine (PPD) is an aromatic amine that has been used as a hair dye for more than a century. While it is allowed in hair dyes, the FDA otherwise prohibits its use on the skin. Unfortunately, illicit use of PPD in temporary henna tattoos has led to sensitization to PPD. Although there are alternative aromatic hair dyes such as 3-aminophenol and 2,5-diaminotuluene, they tend to cross-react with PPD due to similar chemistries. A clinical pearl is that PPD can also cross-react with para amino compounds including PABA containing sunscreens, sulfonamides, sulfonylureas, azo textile dyes, and ester anesthetics. Hairdressers have a 4.4 fold increased chance of being sensitized to PPD. (3) Although some hair dye components are reported to be carcinogenic in animals, such evidence is not consistent enough in the case of human studies. Consequently, further research is desirable to critically address the significance of this issue, especially with respect to the safety of hair dye ingredients. (4) It should be noted, however, that hair dyes and other aromatic amines such as o-toluidine (which is banned in cosmetics and dyes, but has still been identified in such products) have been classified by the International Agency for Research on Cancer as probably carcinogenic (group 2A). (2)

In a revealing study by Lind et al, skin exposure to hair dye was measured for 20 hairdressers applying highlights and all-over hair color with the hand rinsing technique. Resorcinol was used as a proxy for hair dye exposure. Applying hair dye and cutting the newly dyed hair were the tasks that contributed most to exposure in treatments for highlights. After cutting all-over-colored hair, all hairdressers had measurable amounts of hair dyes on both hands. The authors concluded that hairdressers are exposed to hair dye ingredients during all steps of the hair dyeing procedure. Cutting newly dyed hair contributes significantly to exposure. For the prevention of occupational disease resulting from hair dye exposure, the authors suggested cutting hair before dyeing it, and wearing gloves during all other work tasks. (2)

Oreskov et al have demonstrated that hairdressers and apprentices may lack knowledge on how to handle gloves correctly. They found that a short demonstration of correct glove use [known and donning and doffing] made a significant difference in the skin protection provided by gloves. (5) Regardless, none of the hairdressers in the study by Lind et al used gloves when cutting newly dyed hair, and most of them stated that it would be impossible to use gloves when cutting hair, but not during other hair dyeing tasks. The hairdressers were concerned that with gloves the entire procedure would take longer, thereby becoming more expensive for the client. (2)

Clearly hairdressers use their hands, but I am pleased that they are using their eyes to detect head and neck disease. Perhaps I am more attuned to this because of Deb, however, I have noticed that increasingly hair stylists are referring patients. Their role in melanoma detection cannot be overstated.

In a series of 11 384 melanoma patients, 7% (n = 799) originated on the scalp. Scalp primaries were more often found in males and were associated with increased Breslow thickness and were more frequently ulcerated compared to all other anatomic sites (P = 0.0001). On multivariate analysis, scalp location was a statistically significant independent predictor of worse melanoma-specific and overall survival. This confirmed that the scalp is independently responsible for the negative prognosis associated with head and neck melanoma. Although the pathophysiology of this difference remains to be determined, these data argue for more rigorous surveillance of this anatomic location. (6)

Black et al found statistically significant gains for correct identification of ABCDE criteria for atypical nevi and melanoma detection in 100 following an instructional video. The proportion of participants feeling “very confident” in their ability to detect suspicious lesions more than doubled following the video. (7)

In conclusion, we have to help hairdressers stay healthy so they can do their job and they can help us do ours. I couldn’t be more proud of Deb.

1. Caroe TK, et al. Occupational dermatitis in hairdressers – influence of individual and environmental factors. Contact Dermatitis 2017; 76: 146-50.
2. Lind M-L, et al. Hairdressers’ skin exposure to hair dyes during different hair dyeing tasks. Contact Dermatitis 2017; 77: 303-10.
3. Vogel TA, et al. p-Phenylenediamine exposure in exposure in real life – a case-control study on sensitization rate, mode, and elicitation reaction in the northern Netherlands. Contact Dermatitis 2015; 72: 355-61.
4. Kim KH, et al. The use of personal hair dye and implications for human health. Environ Int 2016; 89-90:222-7.
5. Oreskov KW, et al. Glove use among hairdresser: difficulties in the correct use of gloves among hairdressers and the effect of education. Contact Dermatitis 2015; 72: 362-6.
6. Ozao-Choy J, et al. The prognostic importance of scalp location in primary head and neck melanoma. J Surg Oncol 2017; 116: 337-43.
7. Black NR, et al. Improving hairdresser’s knowledge and self-efficacy to detect scalp and neck melanoma by use of an educational video. JAMA Dermatol 2017; Dec 6 [Epub ahead of print]


**My thanks to Bruce Brod, MD for his review and suggested improvements of this commentary.

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