Cosmetics: An Overview

Zoe Kececioglu Draelos, MD

Department of Dermatology
Bowman Gray School of Medicine
Wake Forest University
Winston-Salem, North Carolina and
Central Carolina Dermatology
High Point, North Carolina

Cosmetics of the hair, skin, and nails represent an area of

great importance to the practicing dermatologist because
use of these products can enhance the external appearance, create cutaneous disease, or interfere with other
treatment modalities. Furthermore, the dermatologist is the
physician best suited to aid patients in appropriate cosmetic
product selection and use.
This article is an overview of the most important currently marketed cosmetics for the hair, skin, and nails. It
discusses the use of hair cosmetics to alter the shape, color,
thickness, and cosmetic appearance of the hair. Hairremoval techniques are also discussed. Nan polishes and
prostheses to alter nail color and length are examined. Finally, skin cosmetics and toiletries for the face and body in
the form of cleansers, toners, exfoliants, masks, moisturizers, specialty creams, and antiperspirants/deodorants are
evaluated in terms of formulation, as well as therapeutic
versus aesthetic benefit.
Introduction

Zoe K. Draelos, MD, is a clinical assistant

professor of dermatology at Bowman Gray
School of Medicine in Winston-Salem, North
Carolina. She is also in private practice with the
Central Carolina Dermatology Clinic in High
Point, North Carolina. Dr. Draelos is a graduate
of the University of Arizona School of Medicine
where she also completed her dermatology
residency. Her special interests are cosmetics
and cosmetic surgery.

Curr Probl Dermatol, March/April 1995

Myriad cosmetics and toiletries exist to groom and alter the

appearance of the hair, nails, and skin. Hair cosmetics exist to
cleanse, condition, curl, and dye the hair. Hair prostheses, in
the form of additions, integration systems, wigs, hairpieces, and
forms, can be used effectively to camouflage hair loss. Hair can
also be removed in areas where it is unwanted. The dermatologist should understand the use of these hair cosmetics, toiletries, and prostheses in the management of patients with scalp
disease or cosmetically damaged hair.
An understanding of nail cosmetics, in the form of nail polish, repair kits, tips, and sculptures, similarly should be part of
the dermatologist's armamentarium, not only to camouflage nail
disease, but more important, to recognize nail problems due to
product use.
Skin-care products, in the form of cleansers, toners, exfoliants,
masks, moisturizers, specialty creams, and antiperspirants/deodorants, may conflict with or augment the treatment of cutaneous dermatoses. Certain products may even be the cause of
skin problems. The dermatologist can provide total skin care for
the patient by addressing not only topics of skin disease but also
a customized skin-care maintenance routine.
This overview is designed to provide an introduction to cosmetics for the practicing dermatologist.

TABLE 2. Hair conditioner types

TABLE 1. Shampoo formulation

Detergent

Advantages

Disadvantages

Conditioner type

Application method

Anionic

Excellent cleansing

Instant
Deep

Nonionic

Leaves hair
manageable
Nonirritating to eyes,
leaves hair
manageable

Leaves hair
harsh
Mild cleansing
Mild cleansing

Leave-in

Applied after shampooing and rinsed

Applied to moistened hair with or
without heat and removed with
shampooing
Applied after towel drying of hair
before styling, removed with next
shampooing

Amphoteric

Hair Cosmetics
Hair cosmetics and toiletries widely used by both
men and women include shampoos, conditioners,
permanent waves, and dyes. Dermatologists may
find the need to provide information to patients
with hair loss of a temporary or permanent nature.
This section also discusses hair prostheses such as
hair additions, hair integration systems, wigs, hairpieces, and forms. Lastly, techniques for hair removal are presented.

Hair Shampoos
Shampoos are specially designed liquid cleansers
for the hair. They differ from traditional bar soaps
in that they do not leave behind "scum," which can
adhere to the hair shaft, rendering it dull and
greasy.' This problem is particularly pronounced in
areas where the water contains a high mineral concentration; therefore, shampoos contain sequestering agents to chelate magnesium and calcium ions,
eliminating the insoluble soaps and salts.
In addition to sequestering agents, shampoos
also contain detergents, foaming agents, conditioners, thickeners, opacifiers, softeners, fragrances,
preservatives, and other specialty additives," Many
of these ingredients (such as the foaming agents,
thickeners, opacifiers, softeners, fragrances, and
specialty additives) are added to improve consumer
appeal, because most individuals believe that abundant fragrant suds will do the best job of cleansing
the hair. This is not true. The value of the shampoo lies in the detergents selected to remove dirt
and sebum and the added conditioners to leave the
hair manageable.
Shampoo detergents can be chemically classified
as anionics, nonionics and amphoterics (Table 1).3
The anionics are excellent cleansers; however, they
may leave the hair feeling dry and coarse. The nonionics are not so effective at removing dirt and sebum but leave the hair more manageable. Amphoteric detergents are also mild cleansers and leave
the hair manageable but are unique in that they do
46

not irritate the eyes," Many shampoos combine detergents from each of these three groups to produce a wide variety of formulations for consumer
needs. Oily-hair shampoos generally employ anionic detergents for optimum sebum removal,
whereas baby shampoos employ amphoteric detergents to minimize eye irritation.
Shampoos are an infrequent cause of irritant and
allergic contact dermatitis because of their short
contact time with the skin. They can, however, contribute to xerosis and resultant eczematous dermatoses because of their ability to remove sebum.
Conditioning agents may be added to shampoo
formulations to leave the hair easy to comb, resistant to static electricity, manageable, and able to
hold a set.

Hair Conditioners
Conditioning agents may be added to shampoos,
a formulation known as a conditioning shampoo,
or may be applied as a separate product. Conditioning shampoos produce minimal cleansing and
minimal conditioning, which may be appropriate
for the patient who shampoos on a daily basis,"
Generally, however, the conditioner is applied as a
separate product in the form of an instant conditioner, deep conditioner, or leave-in conditioner
(Table 2).7

Instant Conditioners.- Instant conditioners are

applied after shampooing before the hair is toweldried. They provide minimal repair to damaged
hair but are excellent at increasing the manageability of hair," Usually, conditioning agents employed
in this formulation are cationic detergents, also
known as quaternaries or quaternary ammonium
compounds or quats, or hydrolyzed proteins. The
cationic detergents are effective at smoothing the
cuticle and neutralizing static electricity." For this
reason, they are excellent conditioners for patients
with permanently dyed or waved hair in which the
cuticle has been disrupted during chemical processing.
Curr Probl Dermetol, March/April 1995

Protein-containing instant conditioners, on the

other hand, are excellent for individuals with damaged hair and split-ends, also known as trichoptilosis. The proteins can temporarily diffuse into the
hair shaft, if their molecular weight is small, and
strengthen the hair while mending split ends. The
proteins are removed, however, with shampooing,
so the protein instant conditioner must be reapplied. The source of the protein (placenta, egg, keratin, collagen, etc.) is not so important as its particle
size in determining the effectiveness of this type of
conditioner.?"

Deep Conditioners.- Deep conditioners are designed to condition and repair the hair more thoroughly, as the name implies. These products are
applied before shampooing and left on the hair for
20 to 30 minutes. Usually the hair is moistened before application, and external heat may be applied
to increase conditioner penetration into the hair
shaft. Deep conditioners may contain oils to increase the moisture content of the hair shaft or proteins to aid in hair-shaft repair. These products are
used on a weekly or biweekly basis, as frequent use
would render the hair shaft limp and difficult to
style.
Leave-in Conditioners.- Leave-in conditioners
are applied to the hair after towel-drying and not
removed until the subsequent shampooing. Products designed for straight hair are known as blowdrying lotions or hair thickeners. They contain synthetic polymers that coat the hair shaft, making it
appear thicker, shinier, and more manageable. Special leave-in conditioners are used by black and
Asian individuals with tightly kinked hair to aid in
combing, provide additional shine, improve manageability, and enhance styling options." These
products are known as pomades, which are creams
or ointments, or brilliantines, which are liquids or
gels.
Instant and deep conditioners are an infrequent
cause of contact dermatitis because of their short
contact time with the skin. Leave-in conditioners
designed for black patients, on the other hand, are
known for their ability to cause comedones, known
as pomade acne.f The comedones are due to petrolatum, lanolin, and vegetable oils contained in
pomades and oily brilliantines that remain in the
hair for days to weeks, depending on shampooing
frequency.
Hair Permanent Waves
Methods of waving and curling straight hair have
been practiced since ancient Egyptian times when
Curr Probl Dermetol, March/April 1995

TABLE 3. Cold permanent wave procedure

1. Initial shampooing of hair to remove sebum and dirt, as
well as entry of water into the hair's disulfide bonds
2. Sectioning of the hair into 30 to 50 areas, depending on
hair length and thickness
3. Wrapping the hair on the proper-sized rod with
sufficient tension. Tissue paper squares are placed over
the ends of the hair shafts before wrapping
4. Applying the waving lotion for 5 to 20 minutes
5. Examining a sample curl to determine if the desired
result has been obtained
6. Neutralizing the hair with the appropriate solution,
followed by thorough water rinsing
7. Drying and styling of the hair

water and mud were applied to hair wound on

sticks and allowed to dry in the sun. The ancient
Greeks refined the technique through the use of hot
irons, which were wrapped with hair. These techniques, however, represent only temporary methods of altering the curl of the hair. The first permanent hair-waving solution was developed by
Nessler in 1906 and consisted of borax paste combined with external heat, but it was very damaging
to the hair shaft.l'' The introduction of ammonium
thioglycolate solutions in the 1930s by McDonough
allowed the elimination of heat; thus, the first coldwave solution was born.?"
Interestingly enough, this cold-wave solution,
with slight variations, is still popular today. It is estimated that more than 65 million permanent
waves are sold in salons and 45 million home waves
are performed on an annual basis in the United
States. The method used in performing a modem
cold permanent wave is summarized in Table 3.
The chemistry behind cold permanent waving
may be divided into three processes: chemical softening, rearranging, and fixing. 1s Initially, the softening occurs when a thiol compound penetrates the
hair shaft to cleave the hair keratin disulfide bond
and produce cysteine residues. The hair protein
structure then rearranges to relieve the internal
stress created by wrapping the hair around a curler
with tension (Fig. 1).16 An oxidizing agent is finally
applied to reform the disulfide crosslinks and fix
the hair.!"
A permanent wave is designed to last 3 to 4
months. Even though the curl is designed to be permanent, some relaxation occurs with time as the
hair returns to its original configuration. Most of
the curl relaxation occurs within the first 2 weeks
after processing, a fact that is reassuring to the patient who has had an undesirable result. New hair
growth also decreases the curled appearance of the
hair.
47

TABLE 4. TYPes of cold permanent waves

Permanent wave
type
Alkaline
Buffered alkaline

,--------------............--_-._
-_
-------_110-"'---

Exothermic

'::::"""''''--''

Advantages

Disadvantages

Tight, long-lasting
curl produced
Tight, long-lasting
curl produced
Produces heat for
client comfort

Harsh on hair

J ... . . - . . . - . - -

-~

:::=-...=--

~-- '

Self-regulated
Acid

Limits hair
damage
Mild on hair

Sulfite

Less odor

FIG. 1. The hair is wound around mandrels or rods to obtain the

desired curl. Large mandrels create loose curls, whereas smaller
mandrels create tight curls.

Problems Associated with Permanent Waving.Patients may consult a dermatologist after an undesirable permanent wave result over concerns
that their hair is "falling out." Careful examination
will reveal that lost hairs do not contain a hair bulb
but rather are fracturing at the exit point from the
scalp. This is the area of maximum stress on the
hair shaft that has been weakened by the
permanent-waving procedure. Factors that contribute to excessive hair breakage include
1. Hair that has been wound around the perming rods with too much tension, rendering
the hair shaft brittle and inelastic.
2. Hair that has been permanently waved
around very small rods, thus requiring more
disulfide bond rearrangement.
3. Hair that has been permanently waved with
a strong waving lotion, also causing more
disulfide bond rearrangement.
4. Hair that has been permanently waved too
frequently. The procedure should not be repeated more than every 3 to 4 months, depending on the rate of new virgin hair
growth.
5. Hair that was insufficiently neutralized, so
the disulfide bonds were not completely reformed. Ideally, the neutralizer should be
divided into two parts, with the hair being
rinsed and neutralized twice.
6. Hair that was processed too long, allowing
excessive disulfide bond breakage.
7. Hair that was permanently dyed first
and then permanently waved. The hair
should always be permanently waved first,
followed by the permanent dyeing
procedure.
48

Less harsh on
hair
Must be properly
mixed to
prevent hair
damage
Loose curl
produced
Loose curl
produced
Loose curl
produced, long
processing time

Permanent Wave Types.- The various types of

permanent waves are based on chemical differences in the waving lotion. Waving lotions consist
primarily of a reducing agent in an aqueous solution with an adjusted pH. The most popular reducing agents are the thioglycolates, glycerol thioglycolates, and sulfites. On the basis of waving-lotion
type, permanent waves can be classified as alkaline,
buffered alkaline, exothermic, self-regulated, acid,
and sulfite-based. Table 4 summarizes the advantages and disadvantages of each of these permanent wave products.
ALKALINE PERMANENTS.-Alkaline permanents use
ammonium thioglycolate or ethanolamine thioglycolate as the reducing agent in the waving lotion."
These products produce a tight, long-lasting curl.
However, the high pH of 9 to 10 allows hair-shaft
swelling, which can cause problems in individuals
with permanently dyed hair.
BUFFERED ALKALINE PERMANENrs.- To reduce the hair
swelling encountered because of the pH of alkaline
permanent waves, a buffering agent such as ammonium bicarbonate is employed.l'' These products
are known as buffered alkaline permanents and result in a tight curl at a pH of 7 to 8.5. Their advantage is the production of a tight, long-lasting curl
with less hair damage.
ExOTHERMIC PERMANENTS.- Exothermic permanent
waves produce heat as a by-product to increase client comfort. The heat is produced when an oxidizing agent, such as hydrogen peroxide, is mixed
with the thioglycolate-based waving lotion immediately before application to the scalp. Irreversible
Curr Probl Dermatol, March/April 1995

hair damage will result if the waving lotion is not

mixed with the oxidizing agent before application.
For this reason, exothermic permanent waves are
mainly available for professional use only.
SELF-REGUlATED PERMANENTS.- Self-regulated permanent waves are designed to limit the amount of hair
disulfide bond breakage so that irreversible hair
damage is prevented. This is accomplished by adding dithioglycolic acid to the thioglycolate-based
waving lotion and allowing the reaction to reach
equilibrium.

ACID PERMANENTS.- Acid permanent waves occur in

an acidic environment with a pH of 6.5 to 7.3.2 0
They are based on thioglycolate esters such as glycerol monothioglycolate. The lower pH is an advantage because less hair-shaft swelling occurs than at
higher pH levels; thus, hair damage is minimized.
These products result in a looser, less long-lasting
curl but leave the hair soft. They are ideal for permanently dyed or bleached hair.
The glycerol monothioglycolate in this type of
permanent wave is responsible for allergic contact
dermatitis in both beauticians and clients." The
hair may continue to be allergenic even after all
products have been thoroughly rinsed from the
hair.
SULFITE PERMANENTS.- Sulfite permanent waves are
mainly marketed for home use and have not found
popularity among salons in the United States. They
have reduced odor but require a long processing
time at a pH of 6 to 8. A conditioning agent must
be added to the formulation, as sulfite permanent
waves can leave the hair feeling harsh.

Hair Dyes
The ingenuity of the cosmetic chemist has allowed the development of hair-dyeing products
with the ability to lighten, darken, or alter the hair
color for various lengths of time. Hair dyes can be
divided into several types: gradual, temporary,
semipermanent, and permanent.

Gradual.- Gradual hair dyes, also known as metallic or progressive hair dyes, require repeated application to result in gradual darkening of the hair
shaft. They employ the metal salt lead acetate,
which reacts with sulfur-containing substances in
the hair cuticle, giving the hair a characteristic
smell. This product will change the hair color from
gray to brown over a period of weeks.f There is no
control over the final color of the hair, only the
depth of color, and lightening is not possible.
Curr Probl Dermetol, MarchiApril1995

FIG. 2. Blue and purple temporary hair dyes can be used to eliminate unwanted brown and yellow overtones from gray hair. If too
dark a color is selected, however, the hair may appear purple.

Gradual hair dyes are most popular among men

who do not wish to effect a rapid color change and
like a product that can be applied in the privacy of
their own homes. Gradual dyes cannot be combined with permanent waving or permanent dyeing procedures, as unreliable results and hair damage may result.

Temporary.- Temporary hair dyes are named

for their ability to be removed with one shampooing. They are formulated with water-soluble acid
dyes adapted from the textile industry but can only
remove unwanted tones, add highlights, or subtly
color the hair to a darker shade. Their particle size
is too large to penetrate through the cuticle, accounting for their temporary nature." These products are generally hypoallergenic and do not produce hair-shaft damage.
They are most popular among women who have
gray hair with undesirable brown to yellow undertones. To obtain a whiter platinum hair color, a
blue or purple temporary rinse is applied after
shampooing (Fig. 2).
Semipermanent.-Semipermanent hair dyes are
removed in four to six shampooings because of
their intermediate-sized particles that can both enter and exit the hair shaft. The dyes employed are
the nitroanilines, nitrophenylenediamines, nitroaminophenols, azos, and anthraquinones. These
products are popular among both men and women
for adding shades of brown to the hair or covering
less than 30% gray hair. Hair lightening is not possible.i"
Permanent.- Permanent hair dyes are unique in
that their color is long-lasting and the hair can be
49

Bleaching.- Permanent dyeing allows shades to

be obtained both lighter and darker than the patient's original hair color (Fig. 3A and B). Higher
concentrations of hydrogen peroxide can bleach
melanin; thus, the oxidizing step functions both in
color production and bleaching. However, hydrogen peroxide cannot remove sufficient melanin
alone to lighten dark brown or black hair to blonde
hair. Boosters, such as ammonium persulfate or potassium sulfate, must be added to achieve great degrees of color lightening. These are a possible
source of allergic contact dermatitis."
Hair bleaching is by far the most damaging procedure that can be performed on the hair; it accounts for the majority of the cosmetic problems
associated with permanent hair dyes. Problems are
most frequently encountered in the brunette patient who has red undertones to her hair. She technically must first bleach her hair to a platinum
blonde color and then dye her hair to the desired
shade of blonde. Problems arise because reddishbrown hair contains both eumelanin and
pheomelanin pigments. Eumelanin pigments are
removed by peroxide bleaching agents, but
pheomelanins are more resistant to removal. Failure to remove the reddish pheomelanin pigments
results in a reddish color, known as "brassy overtones," that appear 1 to 2 weeks after the bleaching/dyeing procedure. This brassy color is due to
the permanent dye molecules being removed from
FIG. 3. Permanent hair dyes are popular for their versatility in dye- the hair shaft with shampooing.
There are two approaches to this problem. One
ing the hair lighter (A) or darker (B). The hair must be redyed as
the new hair growth appears.
is to suggest that a higher volume peroxide solution be used to more completely remove the
dyed both lighter and darker. This tremendous ver- pheomelanins during the bleaching procedure.
satility makes this dye type the most popular on the This, however, will further weaken the hair shaft by
market today, occupying approximately 70% of hair stripping additional protein, resulting in increased
dye sales. These products are a source of both irri- hair-shaft breakage. The patient should be countant and allergic contact dermatitis and should be seled to select a darker hair shade more like her
patch tested before use.
own natural shade. Redyeing the hair to a darker
This type of hair coloring does not contain color will mask the undesirable reddish color.
dyes but rather colorless dye precursors that
Because the color that is produced is permachemically react with hydrogen peroxide inside nent, new hair growth will be of the patient's
the hair shaft to produce colored molecules. The natural color. This means that redyeing is necesprocess entails the use of primary interme- sary, usually every 2 to 3 months, depending on
diates (p-phenylenediamines, p-toluenediamine, how quickly the hair grows. A variation on permap-aminophenolsl that undergo oxidation with hy- nent dyes, known as a demipermanent dye, is
drogen peroxide. These reactive intermediates are designed for women with less than 40% gray hair
then exposed to couplers (resorcinol, I-naphthol, who wish to cover the gray and obtain brown or
m-aminophenol, etc.) to result in a wide variety of reddish tones. This dye is designed to minimize
indo dyes." These indo dyes can produce shades the color difference between dyed hair and fresh
from blonde to brown to black with highlights of hair growth.
gold to red to orange. Variations in the concentraIf the hair is to be both permanently dyed and
tion of hydrogen peroxide and the chemicals se- permanently waved, the waving procedure should
lected for the primary intermediates and couplers be performed first, followed by the dyeing proceproduce this color selection."
dure in 10 days. Reversal of the two processes can
50

Curr Prabl Dermetol, March/April 1995

produce an undesirable hair color and induce increased hair-shaft cuticular damage.

Hair Additions
Hair additions are a semipermanent method of
camouflaging partial, localized hair loss. They may
be obtained in full-service beauty salons or at a salon that specializes in providing only hair additions. Hair additions are styled with the existing
scalp hair and worn continuously for a period of 8
weeks during swimming, bathing, sleeping, and exercising.
The fibers used to supplement existing scalp hair
can be natural human hair or a synthetic fiber. The
human hair is generally obtained from Asian and
Indian women who grow long hair for commercial
sale. Usually, the human hair is lightened and
redyed to obtain a range of colors and may also be
permanently waved to obtain the desired amount
of curl.
Synthetic fibers are formed from modacrylic,
which is composed of two polymerized monomers:
acrylonitrile and vinylchloride." Care is taken to
mix fibers of varying diameters and color hues, as
not all natural hair shafts are of the same thickness
or color. Additionally, the fiber thickness can be
varied to more accurately simulate hair shaft size
in black, white, and Asian hair.

Braiding.- The most popular method of attaching hair additions employs braiding. This braiding
can be performed on the scalp, also known as
"cornrowing," or off the scalp, also known as "hair
extensions." Individual hair fibers can be woven
into the braids either to thicken their appearance
or to add length. More rapid addition of hair can
be accomplished by sewing woven or "wefted"
bands of hair to the braids.
Bonding.-Synthetic hair fibers can also 'be
melted or "bonded" to the patient's existing hair.
Bonding employs a heated gun to attach clumps
of individual hair fibers to the base of existing scalp
hair. This is a quick method of adding large
amounts of hair to increase fullness. However, traction alopecia is of great concern, and the natural
hair shafts can be damaged during the bonding
procedure. This technique is not recommended for
dermatologic patients.
Gluing.-It is also possible to glue synthetic or
natural human hair additions in place with a cold
latex glue. The existing hair is initially braided into
concentric arcs on the posterior scalp, which are
known as "tracks." These tracks serve as anchors to
which the added hair is glued. This method allows
Curr Probl Dermetol, March/April 1995

addition of large amounts of wefted hair fibers, but

removal of the glue with oil application to the scalp
is difficult.
Successful use of hair additions requires a hair
stylist who is trained in the technique and a client
who will put forth the effort needed to maintain the
added hair. Braided and sewn hair additions pose
the least problem, as no adhesives are used; however, the added hair fibers put increased pull on the
existing scalp hair, which augments the pull already exerted by the tight braids. For these reasons,
traction alopecia is a problem arising in individuals who continually wear hair additions. The traction alopecia seen with additions is identical to that
seen in black patients who wear tightly pulled hair
styles. Initially, only loss of the hair shaft is observed, but with continued traction, the process
can result in loss of the follicular ostia and permanent alopecia. Extensive traction alopecia will eventually preclude the use of hair additions, as no existing scalp hair will be available to anchor the
added hair. Thus an 8-week rest period is recommended between hair additions.
Hair additions also require meticulous care of the
natural hair and scalp. Many individuals fail to
cleanse the hair additions on a regular basis because shampooing loosens the attachments and
decreases the length of time they can be worn. Failure to cleanse the scalp can result in seborrheic
dermatitis and bacterial folliculitis.

Hair Integration
Another method of supplementing localized hair
loss is through the use of hair integration. This
technique is perhaps more useful for the dermatologist, as it does not cause traction alopecia and
does not use attachment methods that may damage existing hair. Hair integration involves the use
of a loose net that is custom-fitted to the scalp. Individual synthetic or human hair fibers are tied to
the net in the color, amount, and degree of curl desired. The netting is then placed over the scalp, and
the patient pulls any existing hair through the
holes in the net. This allows the integration system
to be firmly anchored to the scalp and also creates
a more natural appearance. The net is removed and
replaced as the patient desires. This is an excellent,
but expensive, alternative for the alopecia areata
patient who does not wish to wear a wig.

Wigs, Hairpieces, and Forms

Temporary methods of supplementing thinning
or absent hair include the use of wigs, hairpieces,
51

FIG. 4. Wigs are designed to cover the entire scalp and are attached to existing scalp hair with clips,

TABLE 5. Types of ha irpieces

Hairpiece

Intended function

Fall
Cas cade

To add long hair to sc alp, vertex

To add cu rls or a bun to the posterior
scalp
To add hair to the top of the male scalp
To add bangs to the anterior scalp or
fullness to the top of the scalp in
women
To add hair to entire scalp, except for
the anterior hairline
To add hair' length in th e form of braids
or ponytails

Toupee
Wiglet

Derniwig
Switch

and forms.i" Wigs are designed to cover the entire

scalp and consist of synthetic or natural human
hair fibers sewn to a mesh cap that covers the entire scalp (Fig. 4). These wigs are generally purchased in a wig shop and can be adjusted to fit
most head sizes. However, for the patient who will
likely have long-standing total hair loss, a custom
prosthesis may be more appropriate. Custom wigs
are constructed by making a plaster mold of the patient's scalp, which then serves as a form for the
manufacture of a hard acrylic cap. An adhesive is
used to keep the cap in place on the head. Hair fibers are then glued to the cap and styled while the
patient is wearing the prosthesis. This type of wig
is most appropriate for patients with severe alopecia areata or alopecia totalis in which insufficient
hair is remaining to anchor a more traditional
mass-produced wig .
Hairpieces are designed to supplement localized
areas of hair loss (Table 5). They may be purchased
at a wig salon or custom made to provide added
52

FIG. 5. Hair forms can be used to create the illusion of thicker,

fuller hair. Figure 5A is a form used to create a bun, whereas Figure 58 demonstrates a form used to create a French roll.

hair only in areas where needed. Many patients

find the use of hairpieces more acceptable than
wigs because they can be more securely attached
to existing hair and the patient can style the existing hair along with the hairpiece.
Hair forms provide a meshwork around which
existing hair is styled to create the illusion of fullness (Fig. 5A and B).They are most useful in women
with early female-pattern hair loss.

Hair-Removal Techniques
Hair removal is also an important aspect of cosmetic hair treatments for both men and women. It
is socially important for men to remove facial hair
and women to remove underarm, groin, leg, forearm, eyebrow, and facial hair. Removal techniques
are varied depending on the amount, type, and location of the hair to be removed. Techniques discussed include shaving, depilatories, waxing,
plucking, epilation, and electrolysis (Table 6).
Curr Probl Dermetol, MarchlApril1995

TABLE 6. Hair-removal techniques

Technique

Body sites

Advantage

Disadvantage

Shaving
Epilating
Waxing
Electrolysis
Depilatories

Face, forearms, legs, axilla

Forearms, legs
Face, eyebrows, groin
All
Legs, groin

Inexpensive, painless
Slower, tapered regrowth
Slower, tapered regrowth
May be permanent, tapered regrowth
Painless

Rapid regrowth, irritating

Painful, folliculitis
Painful, folliculitis, bums
Painful, expensive, scarring possible
Irritating, rapid regrowth

Shaving.- Shaving is the most common method

of hair removal for facial hair in men and underarm and leg hair in women. It is inexpensive, fast,
and relatively painless, accounting for its popularity.
It is estimated that the average man will remove
27.5 feet of beard from his face during 55 years of
shaving." Beard growth varies with the time of day
because more growth occurs during the day than
at night. Beard growth also varies with age. Most
white men experience their most rapid beard
growth at age 30. Even though androgens are necessary for initiation of beard growth, declining androgen levels with age do not prevent beard
growth."
Many factors influence the closeness of a shave,
which depends on the optimum interaction between the blade and the skin. Skin factors that contribute to a close shave include abundant facial
subcutaneous fat, resulting in improved resiliency,
and the absence of deep pits around hair ostia. Ostia containing more than one hair shaft are also
subject to increased trauma. A shaving angle of 28
to 32 degrees between the blade and the skin produces the closest shave with the least amount of
irritation. Furthermore, allowing water contact with
the skin for a minimum of 4 minutes diminishes razor burn and improves razor blade life.3 2 The use
of shaving cream is also important to improve skin
lubrication and decrease trauma. Shaving creams
with the highest viscosity seem to prevent surface
trauma more efficiently. Therefore, factors that lead
to increased shaving irritation are new razors, large
shaving angle, thin lathers, high skin tension, shaving against the direction of hair growth, repeat
shaving over a given facial area, and increased shaving pressure.
Preshave products are popular among some
men. These solutions are composed of alcohols
that reduce skin-surface moisture by entraining
water as they evaporate, thus reducing skin-surface
friction." These skin lubricants can reduce blade
life, however, as they increase adherence ofthe hair
to the razor blade.
Aftershave products are designed to soothe the
skin and minimize razor burn. These products are
Curr Probl Dermetol, MarchiApril1995

usually lightly fragranced colognes that may contain menthol, glycerin, and sunscreens. The alcohol content of these products is sometimes high,
which can result in burning on application.

Plucking.- Plucking of the hair is a method of removing the entire hair shaft, including the bulb,
with a pair of tweezers. It is an easy, inexpensive
method of hair removal requiring minimal equipment but is tedious and mildly uncomfortable. Removal of hair from large areas is not feasible, but
plucking is very effective for removal of stray eyebrow hairs or isolated coarse hairs on the chin of
postmenopausal women. Only terminal hairs can
be efficiently plucked, as vellus hairs usually break
close to the skin surface.
Plucking produces little skin damage and provides a longer regrowth period because of complete
hair shaft removal.?" It should be remembered,
however, that repeated plucking of a given hair may
result in follicular damage and failure of the hair
to regrow. For this reason, overplucking of the eyebrow area should be avoided.
Epilating.- Epilating has now come to refer to a
mechanized method of plucking hair. Most epilating devices have a rotating, tightly coiled spring
that traps the hair and pulls it out at the level of
the hair bulb. This more efficient plucking of the
hair provides a long regrowth period but is somewhat painful. Additionally, the device functions
poorly on curved surfaces, such as the underarms,
and can do considerable damage to body areas
with thin skin, such as the face.
Epilating is best used on large flat surfaces such
as the arms and legs, but the hair must be of sufficient length for entrapment in the coiled spring.
Follicular disruption may result in ingrown hairs
and infection." If the epilator is pressed too firmly
against the skin, purpura may result.
Waxing.-Waxing is another variation on plucking of the hair. Two waxing techniques are available: hot waxing and cold waxing. Hot wax uses
beeswax or other low-melting-point waxes, which
are melted in a double boiler and applied to the
area of hair removal with a wooden spatula. The
53

hair then becomes embedded in the wax and is

pulled out at the level of the hair bulb when the
wax is ripped from the skin. Care must be taken not
to burn the skin with the wax. 3 6
Cold waxing, a newer method, employs a waxlike substance that is squeezed as a liquid from a
pouch, thus eliminating the need for melting.
Sometimes cold waxing uses a cloth piece that is
initially applied to the hair removal area, and then
the wax-like product is applied. The advantage of
the cloth is that it provides strength so the wax can
be removed in one piece.
Waxing has the advantage of adequate removal of
both terminal and vellus hairs. This is important on
the upper lip, chin, eyebrows, and cheeks of
women for whom removal of all hair is desirable.
Men generally do not find waxing of facial hair acceptable, as the hair has to grow to at least one sixteenth of an inch before it can be reliably removed
by waxing. Waxing is an excellent method, however,
of removing groin hair in women.

Depilatories.- The goal of a chemical depilatory

is to soften sufficiently the hair shaft above the skin
surface in a short period so it can be gently wiped
away with a soft cloth. Presently marketed chemical depilatories are available in pastes, creams, and
lotions with formulations specially adapted for use
on the legs, bikini area, and face. All formulations
function by softening the cysteine-rich hair disulfide bonds to the point of dissolutiou."
Depilatories are composed of detergents, hairshaft-swelling agents, adhesives, pH adjusters, and
bond-breaking agents. Detergents such as sodium
lauryl sulfate, laureth-23, or laureth-4 remove the
protective hair sebum and allow penetration of the
bond-breaking agent. Further penetration is accomplished with swelling agents such as urea or
thiourea. Adhesives such as paraffin allow the mixture to adhere to the hairs, and adjustment of pH
is important to minimize cutaneous irritation.
Lastly, the bond-breaking agent is able to successfully destroy the hair shaft.
Several bond-breaking agents are available: thioglycolic acid, calcium thioglycolate, strontium sulfide, calcium sulfide, sodium hydroxide, and potassium hydroxide. The most popular commercial
bond-breaking agents are the thioglycolates, as they
minimize cutaneous irritation while effectively
breaking disulfide bonds; however, they are less effective at dissolving coarse hair such as the male
beard. Sulfide bond-breaking agents are faster acting but are more irritating and sometimes produce
an undesirable sulfur odor. Sodium hydroxide, also
known as lye, is the best bond-breaking agent but
is extremely damaging to the skin.
54

Chemical depilatories are designed to be left in

contact with the skin for 5 to 10 minutes, shorter
for fine hair and longer for coarse hair. The products are somewhat selective for hair-shaft damage
because the hair shafts contain more cysteine than
the surrounding skin but are still irritating to skin,
especially if contact is prolonged. The hairs are
ready to be wiped away once they assume a corkscrew appearance. Under no circumstances should
chemical depilatories be applied to abraded or dermatitic skin.
The main advantage to the use of chemical
depilatories is slower regrowth than with shaving
and painless hair removal. The major disadvantage is skin irritation. A study by Richards et al. 3 6
found that fewer than 1% of their female study
population could tolerate facial depilatories. Thus
depilatories are best used for removal of hair on
the legs of women. Darkly pigmented hair seems
somewhat more resistant to removal than lighter
hair, and coarse hair is more resistant than fine
hair.
Both allergic and irritant contact dermatitis can
occur with the use of chemical depilatories. Allergic contact dermatitis is less common but may be
seen because of fragrances, lanolin derivatives, or
other cosmetic additives. Irritant contact dermatitis is common, especially in individuals who use
the product more than once weekly. The product
is not appropriate for any patient with dermatologic problems. Most cutaneous problems can be
remedied by discontinuing use and applying a
topical corticosteroid."

Electrolysis.- The term electrolysis has been

used to describe any electrical method of attempting to destroy the hair follicle permanently without scarring the overlying skin. In actuality, there
are several electrical methods of hair destruction,
including electrolysis, thermolysis, and a blending
of electrolysis and thermolysis techniques. Electrolysis electrochemically destroys the hair follicle
germinative cells, whereas thermolysis uses electrocoagulation to achieve the same result. Blending
of both techniques inflicts thermal and chemical
destruction on the germinative cells."
The most popular electrical method of hair removal is thermolysis, which involves the insertion
of a metal needle into the follicular ostia, followed
by administration of current to the perifollicular tissue. The current induces heating of water within
the tissue, which subsequently destroys the follicular germinative cells. If the tissues have been adequately damaged to prevent hair regrowth, the
hair shaft can be easily plucked with tweezers.
Each hair destroyed must be separately treated;
Curr Probl Dermetol, MarchlApril1995

therefore, only 25 to 100 hairs can be treated per

session.
Electrolysis is most appropriate for removal of localized, sparse areas of hair growth, such as unwanted facial hairs in women. It is not appropriate
for large areas of dense hair growth, such as the
male beard.
The disadvantages of electrolysis are discomfort
from the high-frequency current and the possibility of cutaneous scarring should the area of damage extend beyond the follicular germinative cells.
This hair-removal technique is also expensive and
must be done in a salon. In the hands of a good
electrologist, approximately 15% to 25% of the
treated hairs can be expected to regrow.
The real concern regarding electrolysis is the lack
of regulation, as 23 states do not require licensing
of electrologists. This lack of licensing means that
training and health standards are apt to vary tremendously between salons. Improper techniques
can result in permanent scarring, and failure to
sterilize equipment adequately can result in the
transmission of bacterial and viral infections.
Nail Cosmetics

Nail cosmetics are designed to color and elongate

the nails. Nail color is added through the use of nail
polishes, a well-recognized source of allergic and
irritant contact dermatitis. Sensitive individuals
may develop proximal nail-fold erythema and
edema, fingertip tenderness and swelling, eyelid
dermatitis, or more than one of these. Nail polish
is a popular cosmetic among women and considered an essential part of a good manicure and pedicure. Nail tips and repair kits are also sold to allow
broken nails to appear longer.
Nails can be artificially elongated through the use
of nail sculptures, another popular nail cosmetic,
employing the use of acrylics bonded to the natural nail plate. Sculptured nails can also cause allergic contact dermatitis but are more likely to be associated with onycholysis, onychoschizia, onychomycosis, and nail dystrophy.

Nail Polishes
Nail polishes date from the 1920s, when lacquer
technology was developed. During Word War I, excellent sources of nitrocellulose were developed,
because this substance served as a military explosive. It was discovered that boiled nitrocellulose
could be dissolved in organic solvents. After evaporation of the solvents, a hard, glossy film of nitrocellulose, known as lacquer, was left behind. ExtenCurr Probl Dermetol, March/April 1995

sive research on nitrocellulose lacquer was undertaken by the automobile paint industry. Later, this
technology was directly adapted to the cosmetics
industry in the form of a clear nail polish. In 1930,
Charles Revson developed the idea of adding pigments to the clear lacquer to form an opaque, colored nail polish.?"
As discussed previously, nitrocellulose is the primary film-forming agent in nail lacquer. It produces
a shiny, tough film that adheres well to the nail
plate, but the nontoxic nitrocellulose film is too
hard and must be modified with resins and plasticizers."
The first resin used to enhance the nitrocellulose
film was toluene-sulfonamide-formaldehyde. This
resin is still widely used; however, some individuals are sensitive to this substance, which is found
on the standard dermatology patch-test tray. The
resin has been eliminated in some hypoallergenic
nail enamels. A polyester resin is employed instead,
but sensitivity is still possible, and the enamel is
less resistant to wear.
Nail lacquers also contain plasticizers such as
dibutyl phthalate, which function to keep the product soft and pliable.
All of the nail lacquer ingredients must dissolve
in a solvent, which dries and leaves the colored film
on the nail. Common solvents include N-butyl acetate and ethyl acetate. Other substances, such as
toluene and isopropyl alcohol, may be added to act
as diluents. Diluents keep the nail lacquer thin and
lower its cost.

Nail-Repair Kits and Tips

Long nails are considered a sign of beauty in
modem American culture; therefore, the need to
repair damaged nails and elongate short nails has
created a market for these products. Kits that repair damaged nails generally contain some type of
clear methacrylate-based glue and thin clothreinforced papers. A layer of the glue is applied to
the broken nail to allow the pieces to readhere. The
cloth is then pressed into the glue to reinforce the
broken nail area. Finally another layer of glue, followed by nail polish, is applied. This technique can
be medically useful if a nail has tom through the
nail bed, as excellent pain relief can be obtained
until the damaged nail grows and can be trimmed.
Methacrylate-sensitive individuals may have difficulty with these products; however, methacrylatefree formulations are available.
This same technique can be used to glue artificial nails to the existing nail plate. These are called
"nail tips" and are preformed plastic pieces glued
55

FIG. 6. These ornate nail tips

are glued over the natural nail bed .

to the existing short or broken nail plate (Fig. 6).

Many of the same problems experienced with
sculptured nails are seen.

Nail Sculptures
Sculptured nails are appropriately named, as a
custom-made acrylic nail is formed over and be yon d the existing nail plate. These nails are popular, as the preformed nail tips are not manufactured
in sizes and shapes to meet the needs of all individuals. The nail sculpture is formed by mixing a
powdered methacrylate polymer and a benzoyl
peroxide initiator with a liquid methacrylate ester.
The resulting acrylic is shaped and allowed to
harden on the existing nail plate, which has been
roughened to increase the surface area for sculpture adhesion (Fig. 7). Nail elongation is achieved
by placing a form beneath the nail free edge, to
which acrylic is applied (Fig. 8A, B. and C).The form
is removed following completion. The nails can be
further embellished with fabrics, gold jewels, or colored foils (Fig. 9).
As the natural nails grow, the nail sculptures
loosen around the free edges and move away from
the proximal nail fold. Maintenance care is required every 2 to 3 three weeks, depending on the
speed of nail growth. Dermatologic problems develop when this required grooming is ignored. The
loosening of the nail sculpture from the nail plate
creates a potential space for yeast, fungal, and bacterial overgrowth. Furthermore, the bond between
the sculpture and the natural nail is generally
stronger than the bond between the natural nail
and the nail bed. Onycholysis commonly results
with onychomycosis and bacterial colonization beneath the nail plate as a secondary occurrence.
Allergic reactions may occur to the nailsculpturing material. Currently used preparations
56

FIG. 7. Emery boards, pumic e stones, or grinding drills are used

to roughen the natural nail plate to increase the nail surface area
and improve adherence of the nail sculpture. When the sculptur es
are removed, the nails retain this roughened appearance .

employ ethyl, butyl, and isobutyl methacrylate

monomers, which can cross-react with the methyl
methacrylate monomer in sensitized individuals.
Methyl methacrylate was banned by the FDA for
use in artificial nails in 1976.4 2 .4 3
Skin-Care Cosmetics

Skin-care cosmetics include products designed

to maintain the health of the facial and body skin ,
as well as those products used largely for aesthetic
appeal. The basic needs of facial skin include a
product to remove dirt, sebum, and contaminants
from the face and possibly a moisturizer, if the
complexion is dry. Yet hundreds of products are
marketed through mass merchandisers, drug
stores, cosmetics counters, and boutiques to care
for the facial skin. A product designed for facial skin
care should ideally be noncomedogenic, nonacnegenic, and hypoallergenic. For simplicity, skin-care
cosm etics are divided into cleansers, toners, exfoliants, moisturizers, specialty cream s, and antiperspirants and deodorants.

Formulation Concerns
Dermatologists and cosmetic ch em ists are constantly searching for the perfect cosmetic formulation that is noncomedogenic, nonacnegenic, and
hypoallergenic. Unfortunately, this product does
not exist. There are extensive lists of substances
that are thought to be comedogenic, yet it is practically impossible to find formulations that possess
none of these ingredients because the lists contain
some of the most effective emollients (octyl stearate, isocetyl stearate), detergents (sod iu m lauryl
Curr Probl Dermetol, MarchiApril1995

FIG. 8. This sequence demonstrates how the sculpture is formed over the natural nail plate. Initially, a form is placed beneath the nail (A)
and the sculpturing material is applied (B). The form is then removed once the acrylic has hardened (e).

sulfate), occlusive moisturizers (mineral oil, petrolatum, sesame oil, cocoa butter), and emulsifiers
found in the cosmetic industry. A product line that
avoided all of these substances would not perform
well on the skin and would possess low cosmetic
acceptability. Furthermore, just because a product
does not contain comedogenic substances from
this list does not guarantee that it is noncomedogenic. Conversely, if a product does contain comedogenic substances, this does not necessarily mean
that the product is comedogenic.
Comedogenicity can only be evaluated in light of
the patient's susceptibility to the formation of
comedonal plugs. Some individuals have never developed a comedone and use cocoa butter daily as
a facial moisturizer. For some reason, that is not yet
understood, certain patients develop fewer comedones than others.
Comedogenicity can also be evaluated only in
light of the concentration of the comedogen and
the other ingredients in the product. Few formulations, except for pure petrolatum, are applied to
Curr Probl Dermatol, March/April 1995

FIG. 9. Fabric, such as linen or silk, can be embedded in the acrylic

to add increased strength to the nail sculptures.

the skin in a concentration of 100%. Substances

that are comedogenic when applied to the skin in
concentrations of 100% may not be comedogenic
when applied to the skin in lower concentrations.
57

Individual-ingredient analysis of comedogens in a

product is also not valuable because it does not account for the interaction of substances.
Formulation concerns regarding acnegenicity are
different. Substances that are comedogenic cause
comedones, whereas substances that are acnegenic
cause papules, pustules, or both. Comedogenicity
is due to follicular plugging, whereas acnegenicity
is due to follicular irritation. Thus substances that
are comedogenic are not necessarily acnegenic and
vice versa. Unfortunately, lists of acnegenic substances cannot account for the interaction and
concentration of ingredients. Of more importance
is the individual patient's susceptibility to acne formation. Cosmetics that are acnegenic in one patient are not necessarily acnegenic in another patient.
In a general dermatologist's practice, the phenomenon of acnegenicity due to cosmetics is a
more common occurrence than comedogenicity
due to cosmetics. This makes acnegenicity a more
important issue than comedogenicity. However, the
incidence of comedone and acne formation due to
cosmetics is rare, considering the number of persons who use such products daily.
Hypoallergenicity is also more complex than simply evaluating the cosmetic ingredients that are
present on the standard patch-test tray. Some allergens are present in too low a concentration in
the final formulation to cause problems in all but
the most sensitive patients. Additionally, a given
cosmetic may be tolerated in one facial site but not
in others, such as around the eyes. The incidence
of allergic reactions to cosmetics is also rare, considering the number of cosmetic users.

Cleansers
Skin cleansers are designed to remove sebum,
dirt, bacteria, and cosmetics from the skin. The basic cleanser categories are soaps, lipid-free cleansers, and cleansing creams.

Soaps.- Until 40 years ago, the standard skin

cleanser was alkaline bar soap, which resulted in
skin irritation and precipitation of calcium fatty
acid salts when used with hard water.?" Synthetic
detergent bars, also known as syndet bars, were developed as an alternative to decrease cutaneous irritation." This is accomplished by adjusting the pH
of the product to that of normal skin, between 5
and 6.4 6
Basic syndet soaps may contain sodium cocoate
and sodium tallowate. which are sodium salts of
fatty acids. Other synthetic surfactants, such as dioctyl sodium sulfosuccinate, sodium lauryl sulfate,
58

and cocamidopropylbetaine, may also be present.

This soap formulation is appropriate for individuals with normal to oily skin.
This basic cleansing bar can be transformed into
a deodorant product through the addition of the
antibacterial triclocarban. This cleanser is appropriate for individuals with oily skin accompanied
by acne. It is somewhat more irritating, however,
as the pH of these products is alkaline, between 9
and 10.
A moisturizing syndet bar, also known as a
beauty bar, contains sodium-laurylisethionate and
sodium soap. Lactic or citric acid is added to
achieve a more neutral pH between 5 and 7.

Lipid-Free Cleansers.-Lipid-free cleansers are

liquid products that clean without true soaps. They
are applied to dry or moistened skin, rubbed to
produce a lather, and then wiped or rinsed for removal. These products contain water, glycerin,
cetyl alcohol, and occasionally propylene glycol.
They leave behind a thin moisturizing film and can
be effectively used to clean and remove facial cosmetics in persons with sensitive skin.
Cleansing Creams.- Cleansing creams are applied to the face both to clean and to moisturize.
They are composed of water, mineral oil, petrolatum, and waxes and are therefore recommended
for extremely dry skin. The classic cream for facial
cleansing was known as cold cream. Cold creams
combine the effect of a lipid solvent such as beeswax with detergent action from borax.
Toners
Toners, in the strictest sense, refer to a fragranced alcohol-containing liquid designed to remove soap residue and produce a sensation of skin
tightness. Before the development of syndet bars
and the widespread use of soft water, a soap film
could indeed be left behind on the face; the film
could be effectively removed with an alcohol-based
product. Minimal soap residue is now present on
the face after cleansing, yet many cosmeticcleansing routines recommend using a toner after
washing with a syndet soap. Toners have now been
formulated for individuals with dry, oily, and normal skins and may be labeled astringents, clarifying lotions, T-zone controllers, skin tonics, and
scruffing lotions.
Alcohol-containing toners are designed to be
used on intact skin by persons with oily complexions. The addition of salicylic acid, menthol, or
witch hazel transforms the toner into a "medicated"
product designed for individuals with acne. LowalCurr Probl Dermatol, March/April 1995

cohol concentrations are used in products for persons with normal skin, whereas the alcohol is replaced with propylene glycol for dry-skin formulations.

Exfolients
Exfoliants are designed to remove, chemically or
mechanically, the outer stratum corneum. The
theory behind exfoliation is that removal of the
"old" damaged skin will speed renewal of the
"young" new skin. Skin physiology does not support
this idea, as the stratum corneum is shed and replaced every 2 weeks in healthy individuals; however, this process may slow with advancing age.
Furthermore, aggressive removal of the stratum
corneum may cause irritant dermatitis and milia in
susceptible individuals.
Chemical exfoliants employ salicylic, lactic, or
glycolic acid to encourage stratum corneum desquamation by decreasing corneocyte adhesion.?" A
more aggressive exfoliation can be achieved with
abrasive scrubbers, which are mechanical exfoliants. The abrasive scrubbing creams employ polyethylene beads, aluminum oxide, ground fruit pits,
or sodium tetraborate decahydrate granules to remove the desquamating stratum corneum from the
face." Aluminum oxide and ground fruit pits provide the most abrasive scrub, followed by polyethylene beads, which are softer. Sodium tetraborate
decahydrate granules become softer and dissolve
during use, providing the least abrasive scrub.

Face Masks
The application of substances to the face for purposes of beautifying the skin is a practice rooted in
history. Cleopatra is said to have applied red wine
to her face to maintain its youthful appearance. The
modem practice of externally applying products to
the facial skin is presently referred to as a "face
mask.t'" Face masks can be a source of both irritant and allergic contact dermatitis, depending on
the mask composition. Face masks can be grouped
into several categories: wax-based, vinyl- or rubberbased, hydrocolloid, and earth-based.

Wax-Based Masks.- Wax-based masks are popular among women for their warm} esthetically
pleasing feel. They are composed of beeswax or}
more commonly, paraffin wax to which petroleum
jelly and cetyl or stearyl alcohols have been added
to provide a soft, pliable material for facial application with a soft brush. The wax is heated and sometimes applied directly to the face or at other times
applied over a thin gauze cloth draped over the
Curr Probl Dermstol, March/April 1995

face. Gauze is used to enable the facial technician

to remove the wax in one piece.
There is a sensation of facial skin tightness as the
wax hardens over the face. Wax-based face masks
are most frequently recommended for individuals
with dry skin because of their temporary ability to
impede transepidermal water loss. This effect is indeed temporary and limited only to the time the
mask is in direct contact with the face unless a suitable occlusive moisturizer is applied immediately
after mask removal.

Vinyl- and Rubber-Based Masks.- Vinyl- and

rubber-based masks are the most popular masks
used at home because they are easily applied and
removed. Rubber-based masks are usually based on
latex, whereas vinyl-based masks are based on filmforming substances such as polyvinyl alcohol or vinyl acetate. They are squeezed premixed from a
tube or pouch and applied with the fingertips to
the face. On evaporation of the vehicle, a thin flexible vinyl or rubber film remains behind on the face.
The mask is generally left in contact with the skin
for 10 to 30 minutes and then removed in one sheet
by loosening at the edges.
Vinyl and rubber masks are appropriate for all
skin types and do indeed leave the skin feeling soft
and refreshed. The evaporation of the vehicle from
the wet mask creates a cooling sensation, and the
shrinking of the mask with drying may give the impression that the skin is actually tightening. These
masks can temporarily impede transepidermal water loss while they are in contact with the skin.
Hydrocolloid Masks.- Hydrocolloid masks are
used both in professional salons and at home. Hydrocolloids are substances, such as oatmeal, that
are of large molecular weight and thus interfere
with transepidermal water loss. These masks are
formulated from gums and humectants and enjoy
tremendous popularity because many specialty ingredients are easily incorporated into their formulation. They are marketed in the form of dry ingredients in a sealed pouch that must be mixed with
warm water before application. The resulting paste
is then smeared over the face with the hands and
allowed to dry.
Hydrocolloid masks also leave the skin feeling
smooth and create the sense of skin tightening as
the water evaporates and the mask dries. Temporary moisturization can occur while the mask is on
the skin. Many specialty ingredients (such as
honey, almond oil, zinc oxide, sulfur, avocado) may
be added to provide tremendous variety.
Earth-Based Masks.-Earth-based masks, also
known as paste masks or mud packs, are formu59

TABLE 7. Moisturizer formulation

Category

Mechanism of
action

Occlusives

Impede
transepidermal
water loss (TEWLJ

Humectants

Attract water

Hydrophilic
matrices

Provide
large-molecularweight barrier to
TEWL
Prevent cell damage
and desiccation

Sunscreens

Substances
Petrolatum, lanolin,
mineral oil,
silicone
derivatives
Glycerin, sodium
PCA, propylene
glycol, proteins,
vitamins
Colloidal oatmeal,
hyaluronic acid

PABA esters,
cinnamate
derivatives, zinc
oxide, titanium
dioxide

lated of absorbent clays such as bentonite, kaolin,

or china clay. The clays produce an astringent effect on the skin, making this mask most appropriate for oily-complected patients. The astringent effect of the mask can be enhanced through the addition of other substances such as magnesium, zinc
oxide, and salicylic acid.

Moisturizers
Moisturizers increase the water content of the
stratum corneum, a substance vital to proper skinbarrier function/" Moisturization can be accomplished through the use of occlusives, humectants,
hydrophilic matrices, and sunscreening agents
(Table 7).51

Occlusive Moisturizers.-Occlusion of the stratum corneum is the most common manner in

which moisturizers restore the barrier to transepidermal water 10ss.52 Occlusive substances are generally oils that prevent water evaporation, such as
petrolatum, lanolin, mineral oil, vegetable oils, fruit
oils, or silicone derivatives. Petrolatum and mineral,
vegetable, or fruit oils may be comedogenic, depending on patient susceptibility, concentration,
and formulation considerations. Lanolin, also a
possible comedogen, is noted as an uncommon
cause of allergic contact dermatitis. A newer occlusive moisturizer, the silicone derivatives, is gaining
popularity because it is noncomedogenic, hypoallergenic, and nongreasy.
Humectant Moisturizers.- Moisture can also
reach the stratum corneum if it is attracted from
60

the dermis. Humectant moisturizers function in

this fashion to attract water. Although it is possible
for humectants to attract moisture from the environment, should the ambient humidity exceed
70%, for all practical purposes the water is attracted
from the dermal tissues. Examples of humectants
include glycerin, sodium pyrrolidone carboxylate
(PCA), propylene glycol, some proteins, and some
vitamins." Many individuals mistakenly think that
collagen and vitamins A and E are added to somehow restore damaged dermal collagen or replace
deficient dietary nutrients in the skin. This is not
true. Collagen proteins and vitamins can function
as humectants to attract moisture to the epidermis
but generally do not alter the structure of the dermis.
The optimum moisturizer includes a combination of ingredients to function as occlusives and
humectants. A humectant used alone will attract
moisture to the epidermis, but if the barrier to transepidermal water loss is damaged, the humectant
will further magnify the xerosis. Therefore, humectants should be combined with an occlusive to trap
the water within the epidermis until the barrier
function can be restored through healing.

Hydrophilic Matrix Moisturizers.- Hydrophilic

matrices are large-molecular-weight substances
that retard water evaporation from the skin. The
traditional example of such a substance is colloidal oatmeal, commonly recommended as a bath
additive for patients with eczematous dermatoses.
A hydrophilic matrix moisturizing ingredient found
in facial creams and lotions is hyaluronic acid. Hyaluronic acid, a normal dermal component, can enhance hydration of the epidermis, thus facilitating
penetration of other substances into the skin.
Sunscreen Moisturizers.- Sunscreening agents
can also be loosely classified as moisturizers. They
prevent epithelial cell damage that may result in
cell desiccation.?" Chemical sunscreens, such as
the p-aminobenzoic acid (PABA) esters and cinnamate derivatives, and physical sunscreens, such
as titanium dioxide and zinc oxide, are incorporated into many "therapeutic" moisturizers. This
type of moisturizer may make extended marketing
claims based on the ability of the sunscreening additive to prevent further dermatoheliosis. It may be
classified as an "environmental protective," "antiaging," "defense," "dual purpose," or "anti-wrinkle"
moisturizing product. Sunscreen-containing moisturizers that claim to be "chemical-free" avoid the
chemical sunscreens and instead contain titanium
dioxide. There are no reported cases of allergic contact dermatitis to titanium dioxide.
Curr Probl Dermetol, March/April 1995

Specialty Creams
Specialty creams are basically moisturizers, as
previously discussed, with an added ingredient intended to give the product an enhanced cutaneous
effect. These additives are then used to expand
marketing claims and create the tremendous variety of treatment creams available for purchase. Currently popular additives include sodium PCA, urea,
lactic acid, glycolic acid, vitamins, herbals, proteins,
and hyaluronic acid.

Sodium PCA.- Sodium PCA, chemically known

as sodium pyrrolidone carboxylate, is a chemically
synthesized substance designed to function as a
natural moisturizing factor on the skin. In the laboratory, skin callus can be softened by diffusing sodium PCA into the tissue. It is hygroscopic and an
excellent humectant used in small concentration in
many liquid cosmetics to prevent thickening due
to evaporation. In this capacity, it is functioning as
a preservative, not a cutaneous humectant. The
dermatologist must evaluate the ingredient listing
to determine the purpose of the sodium PCA in a
given product. Substances listed within the last five
to eight ingredients on a label are probably not
present in sufficient amount to have a therapeutic
effect on the skin.
Urea.-Urea, on the hand, is a time-proven humectant that has recently been rediscovered. It can
diffuse into the outer stratum corneum and reduce
hydrogen bonding, allowing water diffusion, making it a popular additive in creams designed for extra dry skin such as that found on the elbows,
knees, and feet. Urea, a strong cutaneous irritant,
can be adsorbed to talc, minimizing its stinging potential. Thus it can be included in sensitive skin, hypoallergenic formulations. Creams containing urea
must be formulated at an acidic pH to prevent the
urea from decomposing to ammonia."
Lactic Acid.- Some formulations combine urea
with lactic acid to decrease comeocyte adhesion,
as well as to soften callosities. Lactic acid also enhances the water-uptake and water-holding capacity of the stratum corneum. It also can increase the
pliability of the stratum corneum by adsorbing to
the polar groups of keratin chains and reducing adhesion.
Glycolic Acid.- Glycolic acid is additive that has
received tremendous press and a great deal of cosmetic company advertising. It is formed from fermerited sugar cane and has been shown to decrease comeocyte adhesion and increase dermal
ground substance synthesis in the laboratory and
in animal models. It functions as a chemical exfoCurr Probl Dermetol, March/April 1995

liant to remove desquamating stratum corneum

and can be used to smooth rough skin, but it is
rather irritating and may produce stinging on contact. For this reason, many companies are using citrated, esterified, or ammoniated glycolic acid derivativea/"

Vitamins.- Vitamins A, C, and E are popular specialty cream additives. They function as humectants, in the most general sense." Vitamin E, also
known as tocopherol, is a popular cosmetic preservative for its antioxidant properties." It is also being investigated for its cutaneous antioxidant potential when applied topically; however, stratum
corneum penetration is minimal, and vitamin stability is a problem.
Some cosmetic companies are now incorporating
a substance known as "Vitamin F" into high-end facial skin creams. Vitamin F is better known to the
dermatologist as unsaturated linoleic, linolenic and
arachidonic acid. Although these essential fatty acids are not considered vitamins, they are thought
in the cosmetics industry to normalize structural
epidermal phospholipids and cellular cementing
substances. Many of the data to support these
claims are not published by the companies but
rather stored in corporate libraries. They are not
available to the general public.
Herbals.- The most confusing area of specialty
additives in cosmetics is plant derivatives, known
as herbals. The variety of additives is almost endless and can be appreciated only by reading chemical company advertisements in cosmetics and toiletries trade journals. A small list of plant additives
is provided in Table 8, accompanied by their purported cutaneous function. Most cosmetic manufacturers do not formulate their own additives but
rather buy them in bulk from wholesalers.
The area of plant additives is made more confusing by the centuries of beliefs that have surrounded
herbal medicine. There is no doubt that many herbals impart a pleasing smell and color to cosmetics.
Some plant additives, such as nut-derived oils, can
function as emollients and moisturizers. Other
plant additives, such as witch hazel, are wellestablished astringents, whereas allantoin has been
used for years in cosmetics designed for sensitive
skin because of its antiinflammatory properties.
Chamomile is frequently used to impart a pleasant
fresh smell to skin creams, but also for its antiinflammatory capabilities."
Proteins.- Proteins can function as humectants,
depending on their configuration and concentration. For example, hydrolyzed collagen can absorb
up to 30 times its fiber weight in water. Hydrolyzed
61

TABLE 8. Herbals and their purported cutaneous

function

TABLE 9. Miscellaneous additives and their purported

cutaneous functions

Plant additive

Purported function

Additive

Purported function

Allantoin
Almond oil
Aloe vera
Avocado oil
Chamomile (bisabololl
Camphor
Cypress
Elder
Geranium
Hawthorne
Hazelnut oil
Horse tail
Hypericum
Jojoba
Licorice
Linden flower
Lotus
Marigold
Marjoram
Myrrh
Sage
Seaweed
Sesame oil
Shea butter
Wheat germ oil
Witch hazel

Anti-irritating
Emollient
Skin soother, moisturizer
Skin soother
Skin soother
Skin refresher
Skin refresher
Skin toner
Skin softener
Astringent
Emollient
Skin toner
Skin refresher
Humectant, moisturizer
Skin soother, softener
Skin soother
Skin soother, softener
Decrease skin edema
Skin toner
Nail strengthener
Skin toner
Skin soother
Emollient
Moisturizer
Emollient
Astringent

Arachidonic acid
Ceramide
Diatoms
Ground pearls
Mink oil
Mucopolysaccharides
Nucleic acids
Oleic acid
Royal bee jelly
Squalene

Skin soother
Moisturizer
Exfoliant
Skin rejuvenation
Moisturizer
Skin conditioner
Improve skin texture
Moisturizer
Emollient, moisturizer
Moisturizer

elastin is another excellent humectant. However,

the hydrolyzed collagen and elastin do not penetrate to the dermis to rebuild actinically damaged
dermal collagen and elastin fibers, as many patients
mistakenly believe.

Hyaluronic Acid.- Hyaluronic acid is another

cosmetic additive misunderstood by many consumers.1t is a normal constituent ofthe dermis, but
topically applied hyaluronic acid does not augment
existing amounts in the dermis. Hyaluronic acid
too is an excellent humectant. Some cosmetic companies are calling hyaluronic acid a "transdermal
delivery system" because it can increase the skin
penetration of other substances through hydration.
Miscellaneous Additives.- Table 9 contains some
miscellaneous specialty cream additives that are
currently popular. Scientific data to substantiate
the listed purported claims is somewhat sparse.
Antiperspirants and Deodorants
Antiperspirants are intended to reduce axillary
perspiration, whereas deodorants are designed to

62

impart a pleasant smell to the armpits. They are a

popular skin care product used by both men and
women because axillary sweating is considered to
be undesirable.

Mechanism of Axillary odor Production.-Axillary odor is caused by the action of bacteria on sterile eccrine and apocrine sweat. The apocrine sweat
is responsible for a large part of the odor, as it is
rich in organic material ideal for bacterial growth.
Eccrine sweat, on the other hand, is more dilute
and does not provide a high concentration of bacterial nutrients. However, eccrine sweat indirectly
promotes odor by dispersing the apocrine sweat
over a larger area and providing the moisture necessary for bacterial growth. Axillary hair also contributes to odor by acting as a collecting site for
apocrine secretions and increasing the surface area
suitable for bacterial proliferation."
Each person has a unique odor due to sebaceous
gland secretions, the combined effect of the foods
last eaten and the physical or psychological body
state. Therefore, two women may smell differently
even though they are wearing the same perfume.
Taking these factors into account, it is then possible to list methods available to reduce axillary
odor, which include reduced apocrine perspiration, reduced eccrine perspiration, apocrine and
eccrine gland secretion removal, and decreased
bacterial growth/"
Mechanism of Action of Antiperspirants.-Antiperspirants function to reduce axillary moisture,
but their physiologic effect is not completely understood. Holzle and Kligman'" presented evidence demonstrating that aluminum salt-containing antiperspirants alter the physiologic state of
the sweat duct by creating an aluminumcontaining cast within the acrosyringium, causing
duct occlusion.
Curr Probl Dermatol, March/April 1995

Antiperspirant Formulation.- Metal salts of aluminum, zirconium, zinc, iron, chromium, lead, and
mercury have astringent properties on the skin.
The only two metal salts that are presently used in
antiperspirants are aluminum and zirconium. Zirconiu m salts, however, have had an interesting
safety profile over the last 3S years . In 1955, sodium
zirconyl lactate was used in deodorant sticks but
was found to cause axillary granuloma formation .
In 1973, aerosol zirconium-based products were
voluntarily removed from the market by several
manufacturers who had received reports of skin irritation. Aerosol zirconium-based products were
banned by the FDA in 1977, but no such products
were left on the market at that time. Nonaerosol formulations at concentrations less than 20% are still
allowed."
The original antiperspirant formulation developed in 1916 was a 25% solution of aluminum chloride hexahydrate in distilled water. This solution
was so effective that every second or third day application reduced axillary moisture. However, the
solution is extremely irritating to skin and its high
acidity damaging to clothing. Newer, less irritating
aluminum formulations are more popular today,
but they are also less effective. The FDA did express
some concern in 1978 regarding long-term inhalation of aluminum-containing aerosol preparations.?"
Mechanism of Action and Formulation of Deodorants.- Deodorants fun ction either by masking
the axillary odor with a perfume or by decreasing
axillary bacteria. Therefore, many deodorants are
antibacterials. Suitable antibacterial agents include
quaternary ammonium compounds (benzethonium chloride) and cationic compounds (chlorhexidine, triclosan). A popular additive of deodorants
and deodorant soaps, hexachlorophene, was
banned by the FDA in all nonprescription products
in September 1972. Many companies were forced
to reformulate their deodorant products at that
time because it had been shown that brain lesions
were produced in test animals fed high doses of
hexachlorophene.
Sometimes the vehicle of a product can act as an
antibacterial such as ethyl alcohol. Additionally,
certain botanicals such as thyme oil (thymol) and
clove oil (eugen ol) also have antibacterial properties.
Summary
Cosmetics and toiletries for the hair, nails, and
skin are used on a daily basis by men, women, and
Curr Probl Dermatol, March/April 1995

children. It is estimated that the average adult uses

seven to eight different products in his or her
grooming routine. A basic knowledge of these products is valuable to the dermatologist both in advi s ing patients and in diagnosing allergic and irritant
contact dermatitis.
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Curr Probl Dermetol, March/April 1995