Eyelid Allergic Contact Dermatitis Caused by Nickel From a Surprising Source: An Illustrating Case of Illuminating Eye Care

Metal applicators on eye products are trending. We report a case of eyelid allergic contact dermatitis (ACD) caused by nickel in a metal applicator of an eye cream, highlighting a new and unique route of nickel exposure. A 41-year-old female patient presented with eyelid dermatitis (Figure 1a), which appeared a few days after she started to apply a new eye cream, Yves Rocher Anti-age Global, The Illuminating Eye Care, France. Patch testing with the Swedish baseline, extended baseline, cosmetics, and fragrance series, along with the patient's own cosmetics was performed. The readings on days 3 and 7 revealed positive reactions (2+) to nickel(II) sulfate hexahydrate (5% petrolatum) and (1+) to cobalt(II) chloride hexahydrate (1% petrolatum). Testing with other substances, including the eye cream, yielded negative results. The patient reported a self-suspected nickel contact allergy, which she noticed upon exposure to metal jewellery. Despite the negative testing for the eye cream, the patient remained concerned about a potential allergy to the product. Interestingly, the eye cream's applicator featured a metal tip. According to nickel and cobalt spot tests, the tip contained nickel but not cobalt (Figure 1b). To definitively assess the clinical relevance, repeated open application tests (ROATs) were conducted by (1) applying the cream from a plastic container using the patient's fingers, and (2) applying it directly from the tube, which allowed for skin contact with the metal tip (Figure 1c). After three weeks, a positive ROAT was observed only at the site of contact with the metal tip (Figure 1d). This compelling evidence led to a diagnosis of ACD to nickel, conclusively attributed to the direct skin contact with the metal applicator. Metal applicators, including tips and rollers, have become popular in eye cosmetic packaging used in several brands. However, there is no evidence demonstrating their advantages. The safety of the packaging used for cosmetics has been overlooked since it is challenging to identify whether the packages may contain unwanted chemicals, such as formaldehyde contamination in containers [1]. In our patient, the nickel spot test and ROATs were mandatory to confirm the clinical relevance. Notably, the skin on the forearm where the ROATs were performed took longer to elicit a positive reaction compared to the eyelids. Different sources of skin exposure to nickel have been reported [2]. Despite the EU's Nickel Directive, preventing skin sensitisation to nickel remains challenging due to the emergence of new or unaware sources that may not yet be established and regulated [3]. Nickel is a water-soluble substance. As a result, when the metal part interacts with cosmetics containing water, such as creams or gels, nickel can dissolve. When nickel is in contact with the skin in this circumstance, it could cause more significant problems than in a dry condition. Due to this unique route of exposure, additional evidence is required to inform regulatory decisions. In conclusion, this report presents the first documented case of ACD caused by nickel released from the metal tip of an eye cream product. Clinicians should be aware of this route of exposure to nickel. This finding may lead to further regulations regarding the packaging of cosmetic products. Thanisorn Sukakul: writing – original draft, writing – review and editing, investigation, methodology. Jakob Dahlin: supervision, writing – review and editing, investigation, methodology. Cecilia Svedman: writing – review and editing, supervision, methodology. The patients have given written informed consent for the publication of their clinical details and accompanying images. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.