DERMATOLOGICA SINICA 28 (2010) 163166

CAS E R EP O RT

Allergic contact dermatitis induced by zinc pyrithione

in shampoo: a case report

Chih-Wei Hsieh, Mei-Eng Tu*, Yu-Hung Wu

Department of Dermatology, Mackay Memorial Hospital, Taipei, Taiwan

KEY WO R D S AB S T R ACT

Allergic contact dermatitis Shampoo-induced allergic contact dermatitis is difficult to diagnose clinically because
Patch test it can involve multiple and variable areas where the shampoo flows. Zinc pyrithione is a
Shampoo common active agent in medicated shampoo that is known to have good anti-dandruff
Zinc pyrithione and antifungal effects. Despite its low risk of sensitization, cases of allergic contact der-
matitis still occur because of the popularity of such products. We report a 33-year-old
man who developed pruritic rash on his scalp, face, neck, and hands after using a new
shampoo containing zinc pyrithione. A patch test revealed a positive reaction to zinc
pyrithione and personal shampoo containing zinc pyrithione.

Copyright 2010, Taiwanese Dermatological Association.

Published by Elsevier Taiwan LLC. All rights reserved.

Introduction Case report

Shampoo is the most commonly used hair product on the
market. Although it is quickly rinsed away and it is not in
contact with skin for a long period, shampoo-induced al-
lergic contact dermatitis is still the third leading cause of
patients own product-related scalp dermatitis.1 Numerous
ingredients are added to satisfy different kinds of hair char-
acteristics and customers demands.
Zinc pyrithione is a common active ingredient with a
low potential of irritation and sensitization in antidandruff
shampoo; it is often recommended for individuals with se-
borrheic dermatitis or psoriasis. Two mechanisms of anti-
dandruff effects have been studied: (1) zinc pyrithione is an
antifungal agent that interferes with the primary proton
pump in fungus membranes;2 and (2) zinc pyrithione has
cytotoxic effects on rapidly proliferating epidermis cells.3,4
Despite its frequent and widespread use, very few cases of
zinc pyrithione-induced allergic contact dermatitis have been
documented. We present a case of allergic contact derma-
titis due to a shampoo containing zinc pyrithione, which
was further confirmed by a positive patch test result.
*Corresponding author. Department of Dermatology, Mackay Memorial Hospital,
92, Section 2, Zhongshan North Road, Taipei City, Taiwan.
E-mail: tme@ms2.mmh.org.tw
Received: Dec 3, 2009 Revised: Jan 26, 2010 Accepted: Feb 2, 2010
A 33-year-old male cement worker who had no history of
atopic diseases or drug allergy presented to our emergency
room because of itching edematous erythema and erythema-
tous papules over his scalp, forehead, eyelids, ears, nape,
neck, wrists, and hands (Figure 1). This patient had been suf-
fering from increasing dandruff for years. Before the onset
of the skin rash, he had begun using a new anti-dandruff
shampoo (Anti-Dandruff Conditioning Shampoo, manufac-
tured by Procter & Gamble Co., Cincinnati, OH, USA) con-
taining 0.45% of zinc pyrithione. He denied use of hair dye
recently. Under the impression of contact dermatitis to the
new shampoo or cement dust that he was exposed to at
work, a topical steroid and oral hydroxyzine were given
and skin lesions gradually resolved.
One month after he began taking medication, a patch test
was performed with European Standard Series, common
shampoo allergens (Chemotechnique Diagnostics, Malmo,
Sweden), and personal shampoo. Readings were carried out
on days 2, 3 and 7, according to the International Contact
Dermatitis Research Group recommendations. The patient
had positive reactions to zinc pyrithione, the 2% and 5%
dilution of his new shampoo containing zinc pyrithione
(Figure 2 and Table 1). The results of the tests with diluted
shampoo (2% and 5% aq.) were negative in five healthy
164
A B
C D
Figure 1 Edematous erythema, desquamation, and erythematous papules on the patients (A) forehead and eyelids, (B) ear and hairline, (C) nape,
and (D) hands are shown.
2% shampoo
5% shampoo
ZPT
Figure 2 Positive patch test reactions to zinc pyrithione and to sham-
poo in 2% and 5% aqueous forms.
volunteer controls. A positive reaction to cocamidopropyl
betaine of common shampoo allergens was also noted in
the patient, but his shampoo did not contain cocamido-
propyl betaine. Allergic contact dermatitis to zinc pyrithione
was diagnosed.
C.W. Hsieh et al
After the patient stopped using the shampoo containing
zinc pyrithione, he had no recurrence of the dermatitis.
Discussion
The clinical diagnosis of shampoo-induced allergic contact
dermatitis is difficult because of its multiple and variable
distribution. It can present as either scalp dermatitis, eyelid
dermatitis, facial dermatitis, neck dermatitis, dermatitis of
the upper trunk, and even hand dermatitis, or a combi-
nation of these. In fact, the reaction can occur on any sur-
face that is exposed to the shampoo. Since many shampoos
are quite similar in their ingredients, changing from one
suspected shampoo to another may not relieve or improve
the symptoms.
The identification of definite allergens in each case is also
challenging. Most shampoos contain numerous ingredients,
ranging from 4 to 30 ingredients in one shampoo alone.5
Many ingredients are not included in routine patch test series.
Patch tests with personal products may help to identify the
causative allergens.1 Interpreting the results of patch tests
also requires much care because of a high false-positive rate.
Zinc pyrithione-induced contact dermatitis 165

Table 1 Patch test results.

Results*
Tested substance Concentration (%) Vehicle
Day 2 Day 3 Day 7

European standard series () () ()

Shampoo allergens
Zinc pyrithione 1.0 pet. (++) (++) (++)
Resorcinol 1.0 pet. () () ()
Chloroacetamide 0.2 pet. () () ()
Cocamidopropyl betaine 1.0 aq. (+) (+) (+)
2-Bromo-2-nitropropane-1,3-diol 0.25 pet. () () ()
Captan 0.5 pet. () () ()
4-Chloro-3-cresol (PCMC) 1.0 pet. () () ()
4-Chloro-3-xylenol (PCMX) 0.5 pet. () () ()
Imidazolidinyl urea (Germall 115) 2.0 aq. () () ()
Diazolidinyl urea (Germall II) 2.0 aq. () () ()
Patients shampoo containing
0.45% zinc pyrithione 2.0 aq. (++) (++) (++)
0.45% zinc pyrithione 5.0 aq. (++) (++) (++)

*Negative reaction indicated with minus sign, weak reaction (infiltrated erythema) indicated with single plus sign, strong reaction (infiltrated erythema
with papulovesicles) indicated with double plus sign. pet. = petrolatum; aq. = aqueous.

Of all products applied on the scalp, irritant and question-
able patch test reactions occur most frequently in hair
cleaning products because of their unusually long stay and
occlusive conditions in patch tests.1 Selection of a proper
diluted concentration and using a control group can improve
the accuracy of patch tests.
The allergens most commonly present in shampoos are
fragrance, cocamidopropyl betaine, methylchloroisothia-
zolinone/methylisothiazolinone, formaldehyde releasers,
propylene glycol, vitamin E, parabens, benzophenones, iodo-
propynyl butylcarbamate, and methyldibromoglutaronitrile/
phenoxyethanol preservatives.5 Compared with the wide-
spread and frequent use of zinc pyrithione in anti-dandruff
shampoos, allergic contact dermatitis to zinc pyrithione is
extremely rare. The positive patch test rate of zinc pyrithione
ranges from 0.2%6 to 1.2%.7
After reviewing the related English literature, we found
nine additional reports (12 patients) of allergic contact der-
matitis caused by zinc pyrithione.6,815 In all patients, the zinc
pyrithione-containing products were shampoos. Most cases
presented with scalp dermatitis and often there was wide-
spread involvement of the face, neck, shoulders, upper trunk,
and hands where the shampoo may come into contact. The
skin lesions were generally eczematous. In two patients with
psoriasis, it presented as acute exacerbated pustular psoriasis
with Koebners phenomenon after contact dermatitis caused
by zinc pyrithione.14,15 Yates and Finn10 reported one case of
photosensitivity dermatitis and actinic reticuloid syndrome
following contact dermatitis to zinc pyrithione. However,
the causative relationship of photosensitivity is controver-
sial and this phenomenon was not noted in any of the other
cases.
Calnan8 reported the cross-reactivity of zinc pyrithione,
piperazine, hydroxyzine hydrochloride, and ethylenediamine
hydrochloride. In our patient, hydroxyzine was prescribed
to relieve symptoms. No aggravation or new skin lesions was
found.
Our patient also had a positive patch test reaction to
cocamidopropyl betaine, an amphoteric surfactant and a
frequent sensitizer in shampoo.16 Irritant reaction to coca-
midopropyl betaine appears frequently in patch tests.17 Our
case did not use any shampoo containing cocamidopropyl
betaine before the skin rash occurred.
In conclusion, dermatologists should be aware of possi-
ble shampoo-induced allergic contact dermatitis, especially
diffuse dermatitis involving the scalp, face, neck, upper trunk,
and hands. Patch tests should be performed with available
shampoo allergens and personal shampoos to screen for
possible allergens. Careful exclusion of false-positive reac-
tions and testing with a control group may also help clarify
allergens. Patients must be educated to read the ingredients
of shampoos carefully and to avoid allergens. In patients
allergic to zinc pyrithione, cross-reactivity with piperazine,
hydroxyzine, and ethylenediamine hydrochloride may occur.
References
1. Hillen U, Grabbe S, Uter W. Patch test results in patients with
scalp dermatitis: analysis of data of the Information Network
of Departments of Dermatology. Contact Dermatitis 2007;56:
8793.
2. Ermolayeva E, Sanders D. Mechanism of pyrithione-induced
membrane depolarization in Neurospora crassa. Appl Environ
Microbiol 1995;61:338590.
166
3. Priestley GC, Brown JC. Acute toxicity of Zinc pyrithione to
human skin cells in vitro. Acta Derm Venereol 1980;60:1458.
4. Gibson WT, Chamberlain M, Parsons JF, et al. The effect and mode
of action of zinc pyrithione on cell growth. I. In vitro studies.
Food Chem Toxicol 1985;23:93102.
5. Zirwas M, Moennich J. Shampoos. Dermatitis 2009;20:10610.
6. Brandrup F, Menne T. Zinc pyrithione (Zinc Omadine) allergy.
Contact Dermatitis 1985;12:50.
7. Gonzalez Perez R, Aguirre A, Raton JA, et al. Positive patch tests
to zinc pyrithione. Contact Dermatitis 1995;32:1189.
8. Calnan CD, Cited by Fisher AA. Highlights of the First International
Symposium on Contact Dermatitis. Cutis 1976;18:64562.
9. Muston HL, Messenger AG, Byrne JP. Contact dermatitis from zinc
pyrithione, an antidandruff agent. Contact Dermatitis 1979;5:2767.
10. Yates VM, Finn OA. Contact allergic sensitivity to zinc pyrithione
followed by the photosensitivity dermatitis and actinic reticuloid
syndrome. Contact Dermatitis 1980;6:34950.
11. Goh CL, Lim KB. Allergic contact dermatitis to zinc pyrithione.
Contact Dermatitis 1984;11:120.
C.W. Hsieh et al
12. Nigam PK, Tyagi S, Saxena AK, Misra RS. Dermatitis from zinc
pyrithione. Contact Dermatitis 1988;19:219.
13. Pereira F, Fernandes C, Dias M, Lacerda MH. Allergic contact
dermatitis from zinc pyrithione. Contact Dermatitis 1995;33:
131.
14. Nielsen NH, Menne T. Allergic contact dermatitis caused by zinc
pyrithione associated with pustular psoriasis. Am J Contact Dermat
1997;8:1701.
15. Jo JH, Jang HS, Ko HC, et al. Pustular psoriasis and the Kobner
phenomenon caused by allergic contact dermatitis from zinc
pyrithione-containing shampoo. Contact Dermatitis 2005;52:
1424.
16. Li LF. A study of the sensitization rate to cocamidopropyl betaine
in patients patch tested in a university hospital of Beijing. Contact
Dermatitis 2008;58:247.
17. Vilaplana J, Mascaro JM, Trullas C, et al. Human irritant response to
different qualities and concentrations of cocoamidopropylbetaines:
a possible model of paradoxical irritant response. Contact
Dermatitis 1992;26:28994.