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Side effects of cosmetic procedures may masquerade as ocular surface disease
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The cosmetics industry is currently valued at more than $3 billion per year, and its growth does not seem to be slowing down anytime soon. With the pursuit of beauty and the advent of new products being trialed on the eyes of our patients, it behooves us as clinicians to understand these trends and their potential side effects. Patients, both women and men, may present with ocular symptoms after undergoing lid or lash cosmetic procedures or starting a new product. Being able to identify this growing subset of potential causes of ocular surface symptoms is an important differential diagnostic consideration during the clinical workup.
Dry eye disease (DED) and other forms of ocular surface disease (OSD) have been well studied in landmark publications. Studies identify what are deemed masqueraders or co-conspirators of DED: those conditions that are not DED but may cause DED-like symptoms.
Examples of such conditions include allergic conjunctivitis, medicamentosa, floppy eyelid syndrome, conjunctivochalasis and epithelial basement membrane dystrophy, among others. Each masquerader needs to be properly identified in order to treat the primary underlying causes of the patient’s symptoms.
Source: Victoria Viola
We aim to raise awareness of a growing yet often unrecognized category of DED masqueraders for consideration: cosmetic lids and lashes. Here we highlight case reports from our clinical practices as well as provide an overview of some of the current trends and common ocular offenders.
Nail polish
Most people never associate their nail polish as the trigger of their ocular allergies.
Nail varnish has been around since 3000 BC, mostly worn by women. Queen Cleopatra is said to have used natural ingredients such as mixed oils, Arabic gum, powder and henna to paint her nails red. It was said that the stronger shade of red the person wore, the more powerful the person. Similarly, the Chinese used a polish made from Arabic gum, gelatin, egg whites and beeswax. In the 19th century, people began to massage tinted powders and creams into their nails and buff them shiny with, for example, Graf’s Hyglo nail polish paste. Cutex (from its product cuticle extract) produced the first modern nail polishes in 1917 with the introduction of its colored nail glosses.
Manicures are on the rise and the nail polish business is rapidly growing, but with it comes increased concern about nail polish-related dermatitis including involvement of the periocular region and eyelids.
There are two possible mechanisms of action: allergic contact dermatitis and irritant contact dermatitis. Allergic contact dermatitis is a sensitivity reaction to a specific ingredient in the nail polish. Irritant contact dermatitis is caused by repeated exposure to a mild irritant.
A typical manicure that consists of a base coat, top coat and polish can contain dozens of chemicals known to cause allergies and allergy-like symptoms. Gel and acrylic formulas are typically more chemically intensive and require harsher and lengthier removal processes. When cuticle oils, hand creams and nail art supplies are factored in, the potential of allergic reactions increases significantly. Most nail lacquers contain formaldehyde, dibutyl phthalate, toluene, ethyl methacrylate, camphor and formaldehyde resin, all of which can cause dermatological irritations and allergic reactions (Figure 1).
Metallic nail enamel shades may contain nickel, which in itself is associated with allergic reactions, especially in people with eczema and known nickel sensitivities.
A number of articles describe contact dermatitis as a result of nail polish use, with at least 80% of these cases being dermatitis of the face and every second case being dermatitis of the eyelid.
Source: Eric D. Donnenfeld, MD
In a Polish study of 145 women manicurists aged between 21 and 64 years who answered a questionnaire about ocular, nasal and respiratory symptoms, 57.9% reported experiencing ocular itching, redness and tearing. Ninety-three of the respondents further underwent a medical interview by a physician; of those, 22 (24%) reported tearing, dryness, foreign body sensation, redness or itching of their eyes. Ten of the 22 attributed the symptoms to occupational exposure.
Contact dermatitis is also called a delayed hypersensitivity reaction because it generally takes several exposures to the offending substance, or allergen, before it produces a full-blown allergic reaction. At first contact, the allergen is absorbed into the skin, and immune cells called T-lymphocytes generate memory cells to recognize the allergen as harmful at subsequent exposures. An allergy to nail polish is often attributed to eye makeup or skin care products because the initial symptoms are typically expressed around the eyelids, face, ears and neck.
Reactions can include stinging or burning sensations, redness, itching of the eyes, and swelling or even blistering of the lids. Most reactions happen immediately; others can manifest as long as 10 days after the initial contact, making diagnosis much harder.
Eyelash extensions
A case involved a 30-year-old woman who presented with acute right eye redness and irritation for 2 days. She had undergone a cosmetic procedure for upper eyelid eyelash extensions the same day as the onset of symptoms. She said that during the procedure both eyes felt a burning sensation from the glue application, and after completion, her right eye had persistent discomfort of 5 on a scale of 1 to 10. On examination, visual acuity was 20/20 with correction in both eyes. The pertinent findings were nasal conjunctival injection (Figure 2), nasal conjunctival staining and an artificial eyelash found adjacent to the caruncle.
Source: Ashley Brissette, MD, MSc
The artificial eyelash was removed with jewelers forceps at the slit lamp, and the patient was started on topical tobramycin/dexamethasone four times daily and preservative-free artificial tears four times daily for 1 week. Symptoms and signs had resolved at the 1-week follow-up appointment. There was a discussion about risks of eyelash extensions and consideration of removal of the residual eyelash extensions, but the patient refused.
Eyelash extensions are used to enhance the appearance of the natural eyelashes for longer- or thicker-appearing lashes. They are applied to each individual natural eyelash with semi-permanent adhesive and are intended to last until the natural eyelash falls out (approximately 1 to 2 months). To maintain the look of fuller, longer lashes, the extensions need to be reapplied at approximately monthly intervals. The artificial lashes themselves can be made from various materials including mink, synthetic plastics and silk. The adhesive is commonly made from methyl 2-cyanoacrylate, which is known to cause contact dermatitis. Both the lashes and the adhesive are not supposed to come into contact with the skin during application.
Common side effects of this cosmetic procedure include allergic conjunctivitis, contact dermatitis to the glue and/or artificial lash material, and madarosis. Interestingly, the length of these lashes actually interferes with the blink reflex and can lead to poor or incomplete blinks and secondary meibomian gland dysfunction and evaporative dry eye disease. Lastly, because one is to avoid excessive water or touching of the extensions, blepharitis and lid scurf, eyelid excoriations, superficial skin infection or possible preseptal cellulitis can occur due to poor eyelid hygiene.
Permanent eyelash curling or tinting
Otherwise known as an eyelash perm, permanent eyelash curling uses a chemical composition including ammonium thioglycolate to break down the disulfide bonds in the lash hair so that the lashes can be re-molded into a curled position, with the effect lasting until the eyelash falls out. Of note, although the FDA has approved this process as a hair treatment, it has not yet approved it for use around the eyes.
Eyelash tinting is used to darken the natural lashes. The tint is similar to that used in hair dye and contains the same active ingredients for the chemical reaction: para-phenylenediamine, which has been reported to cause madarosis, and hydrogen peroxide. Ocular side effects of the above treatments may include madarosis, allergic conjunctivitis, contact dermatitis, eye irritation, skin staining and chemical burn.
Eyelid tattooing
A case involved a 78-year-old woman who presented with 3 days of eye pain, redness and watery discharge in her right eye. She had undergone cosmetic eyelid tattooing on the upper and lower lids of both eyes 3 days earlier. Examination findings were positive for conjunctival injection of the right eye, with upper and lower eyelid edema and hyperemia (Figure 3). She was treated with topical loteprednol four times a day for 1 week, cold compresses and cold artificial tears every 2 hours, which relieved her symptoms.
Eyelid tattooing, or micropigmentation, was initially introduced for people with alopecia of the eyebrows and has since been used for patients with hair loss due to chemotherapy, burns or medical conditions such as Parkinson’s disease or rheumatoid arthritis, in which it may be difficult to apply makeup to the eye area. However, it is also popular with people as a cosmetic procedure for permanent makeup.
Micropigmentation is similar to regular tattooing in that it uses a needle to insert pigmented granules under the epidermis of the eyelid skin for a permanent eyeliner or eyeshadow effect. The FDA approval of permanent makeup application varies from state to state, as does the training of those performing this procedure (eg, dermatologists, tattoo artists, aestheticians, cosmetologists). Known side effects include madarosis, eyelid erythema, edema, granuloma formation, preseptal cellulitis and other skin infections, and even full-thickness penetration of the eyelid. There are also reports of transmission of HIV and hepatitis from poorly sterilized equipment. Lastly, patients and clinicians should be aware that because these pigments contain iron oxide, they might vibrate during MRI, leading to artifact, inflammation and thermal burn.
Source: Ashley Brissette, MD, MSc
Eyelash growth products
A well-known side effect of the prostaglandin class of medications for the treatment of glaucoma is eyelash growth. After drop instillation into the eye, the lashes were noted to grow longer and thicker, sometimes to the point of needing trimming or epilation for eventual trichiasis and distichiasis. The active ingredient leading to lash growth is prostaglandin analogs, including isopropyl cloprostenate.
Currently, Latisse (bimatoprost ophthalmic solution 0.03%, Allergan) is the only FDA-approved medication for lash enhancement. A number of other companies sell over-the-counter formulations under cosmetic regulations. One such company, which promotes an OTC lash growth product containing isopropyl cloprostenate, is currently undergoing a federal class-action lawsuit regarding failure to disclose side effects. Although prostaglandins are banned from cosmetics in other countries such as Canada, U.S.-based cosmetic companies are permitted to use these ingredients in their products because cosmetic regulations are less stringent than those for medications.
The most common side effects of Latisse include eyelid erythema and pruritus, occurring in 4% of patients studied. Other known effects may involve darkening of the eyelid skin and iris, which may be permanent. Periorbital fat atrophy has also been reported and may be reversible with discontinuation of the treatment.
Conclusion
As these cases illustrate, cosmetics and cosmetic procedures involving the lids, lashes and periocular structures can cause significant ocular surface dysfunction and symptoms. While some cases present with overt severe symptoms acutely after a procedure or initial application of a product, other cases can present with more chronic or indolent symptoms and can easily be misdiagnosed as DED or another common form of OSD such as seasonal allergic conjunctivitis. Any patient presenting with OSD-like symptoms should be questioned about their use of cosmetics and history of lid or lash procedures. While more commonly associated with female patients, cosmetic-related OSD can occur in men too and should not be overlooked. All eye care providers should be made aware of this growing subset of OSD and be prepared to diagnose, treat and educate their patients.
Editor’s note: As of press time, generic pharmaceutical company Akorn Inc. announced it has received FDA approval for an abbreviated new drug application for bimatoprost ophthalmic solution 0.03% indicated for treatment of hypotrichosis of the eyelashes.
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- For more information:
- Ashley Brissette, MD, MSc, can be reached at Weill Cornell Medicine, New York Presbyterian Hospital, 1305 York Ave., New York, NY 10021; email: asb9040@med.cornell.edu.
- Cynthia Matossian, MD, FACS, can be reached at Matossian Eye Associates; email: cmatossian@matossianeye.com.
- Christopher E. Starr, MD, can be reached at Weill Cornell Medicine, New York-Presbyterian Hospital, 1305 York Ave., Room 1133, New York, NY 10021; email: cestarr@med.cornell.edu.
Disclosures: Brissette reports she has financial interests with Allergan, Carl Zeiss Meditec, Johnson & Johnson and Shire. Matossian reports no relevant financial disclosures. Starr reports he has financial interests with Alcon/Novartis, Allergan, Bausch + Lomb/Valeant, Rapid Pathogen Screening, TearLab, Shire, InnoVision Labs, BlephEx, Bruder, Sun Pharma and Kala Pharmaceuticals.