[rosacea] alcohol and rosacea skin

Hello Group,

I was asked by some rosacea sufferers to comment on the potential
irritancy of alcohols....especially in regards to the gentle moisturizing
alcohols such as cetyl, stearyl and benzyl alcohols.  Although one must
understand that it is the product's overall formulation of ingredients
that is important, single ingredients in a perfect cream or lotion can
cause increased chance of irritation especially on rosacea skin.  The
most common form of irritation that we encounter is called cumulative
irritation (i.e., redness or irritation that does not show up immediately,
but slowly progresses  over a period of days or weeks).  This is very hard
to evaluate and is often overlooked by the general physician with regards
to rosacea treatment. 

The medical experts specializing in skin irritation do caution against the
use of all forms of strong alcohol (SD) and some are also now recommending
against the use of cetyl, stearyl and benzyl alcohols due to alterations
that they cause in the lipid bilayer of the epidermis (protective
barrier), and due to cumulative irritation  and allergic contact
dermatitis . 

Among many characteristics, alcohols are commonly used in skin care
preparations and topical medicines as penetration enhancers. 1  This
enhancement in percutaneous penetration may significantly enhance
irritation.  2  The principle mechanism by which alcohol enhances
percutaneous absorption is thought to be alteration in the intercellular
lipid shape or extraction of lipids from the stratum corneum.  1  These
changes in barrier function might make skin more susceptible to damage and
to permeability by other chemicals which may cause irritation.  1, 2
**Alcohol in skin care products can enhance penetration of topical drugs
by physically altering the epidermis, which can lead to subsequent
irritation. 3  In Fisher's Textbook of Contact Dermatitis, alcohol (of
all forms) added to skin care products are reported to cause both irritant
reactions and contact allergic reactions 4

More specifically, I have included a few references below regarding
these gentle thickening alcohols:

 - Dr. Lazar an expert in skin irritant syndromes from the prestigious
Northwestern University Medical School strongly cautions against the
use of 'cetyl alcohol' on irritated, delicate skin (and in fact, puts
it at the top of his list of ingredients to avoid).  5 

 - In a 1990 medical article in Contact Dermatitis, Dr. Tosti and
colleagues indicate that adverse skin reactions to cetyl and stearyl
alcohols are more common than was once thought and thus, is often
overlooked by the general physician.  They advise other physicians to
test patients for adverse irritant skin reactions to these particular
ingredients.  6

 - In the 1998 Textbook of Dermatology, Drs. Griffiths and Wilkinson 
stress that sensitivity to an ingredient in the vehicle is often and/or
easily  overlooked by the general dermatologist.  7  They further
reference several articles that state that nearly all components of the
vehicle can be sensitizers including ˇ§cetyl, stearyl and cetostearyl
alcohols.  7 Alcohol in cosmetics and skin care products can cause
subclinical irritation that cannot be detected by the physician but
will eventually show on patientˇ¦s sensitive skin.

 - Cetyl alcohol is reported to cause skin reactions in the 1999
Contact Dermatitis article Adverse cutaneous reactions to cosmetic
allergens.  8

 - At a session during the IV International Symposia on Contact
dermatitis titled  Frequent contact allergy to higher fatty
alcohols, Dr. Hannuksela cautions that the use of these forms of
alcohols may cause reactions in patients with sensitive skin.  9

 - Stearyl alcohol is listed as causing adverse skin reactions in
Allergic contact dermatitis from topical drugs 10

 - Cetyl alcohol is listed as causing adverse skin reactions in
Allergic contact dermatitis from topical drugs 10

 - In the textbook Unwanted Effects of Cosmetics and drugs used in
Dermatology, alcohols such as emulsifying wax (cetyl, stearyl and SLS)
and pure stearyl alcohol are known to cause adverse skin reactions in
individuals with sensitive skin. 11

 - The emulsifying wax (cetyl, stearyl alcohol and SLS) has been sited
as a frequent and significant cause of dermatitis in  patients with
sensitive skin.  12

 - Steryl and cetyl alcohols are referenced as causing adverse skin
reactions.  4

 - Benzyl alcohol is referenced as an ingredient that can cause
allergic skin reactions in Allergic contact dermatitis from topical
drugs 10

Some more examples of adverse skin reactions by these gentle alcohols
in the  medical literature:

 - Dermatitis from cetyl and stearyl alcohols 13

 - Benzyl alcohol allergy 14

 - Contact dermatitis from fatty alcohols 15

 - Contact dermatitis from cetostearyl alcohol 16

 - A case of contact dermatitis due to impurities of cetyl alcohol 17

 - Contact dermatitis due to corticosteroid cream base cetyl alcohol
and stearyl alcohol 18

 - Irritancy of Alcohols 1

 - Contact dermatitis due to Japanese pharmacopeia cetyl alcohol 19

 - Contact allergy to fludroxycortid and cetyl alcohol 20

 - Allergic reaction to benzyl alcohol in an antimycotic preparation 21

 - Allergic reactions to benzyl alcohol in a sunscreen 22

 - Contact allergy to benzyl alcohol and benzyl paraben 23

So, as you can see, it is not that clear cut -- there are certainly at
least two schools of thought on this issue.  But, let your face decide.
 The only thing that I stress is that a rosacea sufferer should never
fight through any form of irritation because on this particular
game plan, rosacea can go from a cosmetic disease to a debilitating
disease (i.e. result in substantial burning sensations and
frequent/intense flushing episodes).  If your face gets more red or
irritated,  or facial flushing gets worse, you are certainly on the
wrong road (even if your papules are clearing while on that regimen).

Reference List

1. 	Haan P, Meester HM, Bruynzeel DP: "Irritancy of alcohols", in Van
der Valk P, Maibach HI (eds): The Irritant Contact Dermatitis Syndrome.
New York, CRC Press, 1996, pp 65-70
	
2. 	Effendy I, Weltfriend S, Patil S, Maibach HI: Differential irritant
skin responses to topical retinoic acid and sodium lauryl sulphate:
alone and in crossover design.  Br J Dermatol 1996;134:424-430
	
3. 	Zesch A: Skin irritation by topical drugs.  Derm Beruf Umwelt
1983;31:74-78
	
4. 	Rietschel RL, Fowler JF: "Vehicles and preservatives including
formaldehyde, cosmetics, and personal-care products", in Rietschel RL,
Fowler JF (eds): Fishers Contact Dermatitis. edFourth. Baltimore,
Williams & Wilkins, 1995, pp 257-329
	
5. 	Lazar AP, Lazar P: Dry skin, water, and lubrication.  Dermatol Clin
1991;9:45-51
	
6. 	Tosti A, Guerra L, Morelli R, Bardazzi F: Prevalence and sources of
sensitization to emulsifiers: a clinical study.  Contact Dermatitis
1990;23:68-72
	
7. 	Griffiths WA, Wilkinson JD: "Topical Therapy", in Champion RH,
Burton JL, et al. (eds): Textbook of Dermatology . edSixth. Malden,
Blackwell Science, 1998, pp 3519-3563
	
8. 	Goossens A, Beck MH, Haneke E, McFadden JP, Nolting S, Durupt G,
Ries G: Adverse cutaneous reactions to cosmetic allergens.  Contact
Dermatitis 1999;40:112-113
	
9. 	Hannuksela, M. "Frequent contact allergy to higher fatty alcohols".
 1979. San Francisco, March 29-31. IV International Symposia on Contact
Dermatitis. (GENERIC)

10. 	De Groot AC, Weyland JW, Nater JP: "Allergic contact dermatitis
from topical drugs", in De Groot AC, Weyland JW, Nater JP (eds):
Unwanted effects of cosmetics and drugs used in dermatology. edThird.
New York, Elseveir Science, 1994, pp 55-135
	
11. 	De Groot AC, Weyland JW, Nater JP: "Allergic contact dermatitis
from topical drugs", in De Groot AC, Weyland JW, Nater JP (eds):
Unwanted Effects of Cosmetics and Drugs Used in Dermatology. edThird.
London, Elsevier, 1994, pp 657-670
	
12. 	Keilig W: [Contact allergy to cetylstearylalcohol (Lanette O) as a
therapeutic problem in stasis dermatitis and leg ulcer].  Derm Beruf
Umwelt 1983;31:50-54
	
13. 	Gaul LE: "Dermatitis from cetyl and stearyl alcohols".  Arch Derm
1969;99:593
	
14. 	Li M, Gow E: Benzyl alcohol allergy.  Australas J Dermatol
1995;36:219-220
	
15. 	Tosti A, Vincenzi C, Guerra L, Andrisano E: Contact dermatitis
from fatty alcohols.  Contact Dermatitis 1996;35:287-289
	
16. 	Rademaker M, Wood B, Greig D: Contact dermatitis from cetostearyl
alcohol.  Australas J Dermatol 1997;38:220-221
	
17. 	Komamura H, Doi T, Inui S, Yoshikawa K: A case of contact
dermatitis due to impurities of cetyl alcohol.  Contact Dermatitis
1997;36:44-46
	
18. 	Higashiyama M, Yoshikawa K, Kozuka T, Sohma T, Tada M: "Contact
dermatitis due to corticosteroid cream base-cetyl alcohol and stearyl
alcohol".  Skin Research 1989;31(suppl 7):126-131
	
19. 	Kato N, Numata T, Kanzaki T: "Contact dermatitis due to Japanese
pharmacopeia cetyl alcohol".  Skin Research 1987;29(suppl 3):258-262
	
20. 	Hausen BM, Kulenkamp D: [Contact allergy to fludroxycortid and
cetyl alcohol].  Derm Beruf Umwelt 1985;33:27-28
	
21. 	Shoji A: Allergic reaction to benzyl alcohol in an antimycotic
preparation.  Contact Dermatitis 1983;9:510
	
22. 	Edwards EKJ: Allergic reactions to benzyl alcohol in a sunscreen. 
Cutis 1981;28:332-333
	
23. 	Wurbach G, Schubert H, Phillipp I: Contact allergy to benzyl
alcohol and benzyl paraben.  Contact Dermatitis 1993;28:187-188

Regards,

Geoffrey
======
Dr. Geoffrey Nase, PhD

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