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Safety Testing of Cosmetic Products: Overview of Established Methods and New Approach Methodologies (NAMs)

MDPI
Cosmetics
Authors:
  • GenEvolutioN
  • GenEvolutioN

Abstract

Cosmetic products need to have a proven efficacy combined with a comprehensive toxicological assessment. Before the current Cosmetic regulation N°1223/2009, the 7th Amendment to the European Cosmetics Directive has banned animal testing for cosmetic products and for cosmetic ingredients in 2004 and 2009, respectively. An increasing number of alternatives to animal testing has been developed and validated for safety and efficacy testing of cosmetic products and cosmetic ingredients. For example, 2D cell culture models derived from human skin can be used to evaluate anti-inflammatory properties, or to predict skin sensitization potential; 3D human skin equivalent models are used to evaluate skin irritation potential; and excised human skin is used as the gold standard for the evaluation of dermal absorption. The aim of this manuscript is to give an overview of the main in vitro and ex vivo alternative models used in the safety testing of cosmetic products with a focus on regulatory requirements, genotoxicity potential, skin sensitization potential, skin and eye irritation, endocrine properties, and dermal absorption. Advantages and limitations of each model in safety testing of cosmetic products are discussed and novel technologies capable of addressing these limitations are presented.
Cosmetics 2021, 8, 50. https://doi.org/10.3390/cosmetics8020050 www.mdpi.com/journal/cosmetics
Review
Safety Testing of Cosmetic Products: Overview of Established
Methods and New Approach Methodologies (NAMs)
Manon Barthe
1
, Clarisse Bavoux
2
, Francis Finot
3
, Isabelle Mouche
3
, Corina Cuceu-Petrenci
3
, Andy Forreryd
4
,
Anna Chérouvrier Hansson
4
, Henrik Johansson
4
, Gregory F. Lemkine
5
, Jean-Paul Thénot
1
and Hanan Osman-Ponchet
1,
*
1
PKDERM Laboratories, 45 Boulevard Marcel Pagnol, 06130 Grasse, France;
Manon.barthe@pkderm.com (M.B.); jean-paul.thenot@pkderm.com (J.-P.T.)
2
CEHTRA, 15 Rue Aristide Briand, 33150 Cenon, France; clarisse.bavoux@cehtra.com
3
GenEvolutioN, 4 rue des Fréres Montgolfier, 78710 Rosny Sur Seine, France;
francis.finot@genevolution.fr (F.F.); Isabelle.mouche@genevolution.fr (I.M.);
corina.cuceu@genevolution.fr (C.C.-P.)
4
SenzaGen AB, 22381 Lund, Sweden; andy.forreryd@senzagen.com (A.F.);
Anna.C.Hansson@senzagen.com (A.C.H.); Henrik.Johansson@senzagen.com (H.J.)
5
Laboratoire Watchfrog, 1 rue Pierre Fontaine, 91000 Evry, France; lemkine@watchfrog.fr
* Correspondence: hanan.osman.ponchet@pkderm.com
Abstract: Cosmetic products need to have a proven efficacy combined with a comprehensive toxi-
cological assessment. Before the current Cosmetic regulation N°1223/2009, the 7th Amendment to
the European Cosmetics Directive has banned animal testing for cosmetic products and for cosmetic
ingredients in 2004 and 2009, respectively. An increasing number of alternatives to animal testing
has been developed and validated for safety and efficacy testing of cosmetic products and cosmetic
ingredients. For example, 2D cell culture models derived from human skin can be used to evaluate
anti-inflammatory properties, or to predict skin sensitization potential; 3D human skin equivalent
models are used to evaluate skin irritation potential; and excised human skin is used as the gold
standard for the evaluation of dermal absorption. The aim of this manuscript is to give an overview
of the main in vitro and ex vivo alternative models used in the safety testing of cosmetic products
with a focus on regulatory requirements, genotoxicity potential, skin sensitization potential, skin
and eye irritation, endocrine properties, and dermal absorption. Advantages and limitations of each
model in safety testing of cosmetic products are discussed and novel technologies capable of ad-
dressing these limitations are presented.
Keywords: cosmetic product safety; non-animal-testing methodologies; dermal absorption;
skin irritation; skin sensitization; genotoxicity; endocrine disruptors
1. Introduction
Cosmetic products need to have a proven efficacy combined with a comprehensive
toxicological assessment. The 7th Amendment to the European Cosmetics Directive has
banned animal testing for cosmetic products and for cosmetic ingredients in 2004 and
2009, respectively. Then, the European Cosmetic Regulation N°1223/2009 and the specific
Regulation N°655/2013 specify the required data to proof the safety and support the
claims. Largely driven by regulatory authorities, a wide range of alternatives to animal
testing have been developed and validated for safety testing of cosmetic products and
adopted as test guidelines (Figure 1). This review discusses the main in vitro alternative
models used in safety testing of cosmetic products and cosmetic ingredients with a focus
on regulatory requirements, genotoxicity potential, skin sensitization potential, skin and
eye irritation, endocrine properties, and dermal absorption. Advantages and limitations
Citation: Barthe, M.; Bavoux, C.;
Finot, F.; Mouche, I.; Cuceu-Petrenci,
C.; Forreryd, A.; Chérouvrier-
Hansson, A.; Johansson, H.;
Lemkine, G.F.; Thénot, J.-P.; et al.
Safety Testing of Cosmetic Products:
Overview of Established Methods
and New Approach Methodologies
(NAMs). Cosmetics 2021, 8, 50.
https://doi.org/10.3390/
cosmetics8020050
Academic Editor: Kalliopi Dodou
Received: 21 May 2021
Accepted: 8 June 2021
Published: 11 June 2021
Publisher’s Note: MDPI stays neu-
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Copyright: © 2021 by the authors. Li-
censee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and con-
ditions of the Creative Commons At-
tribution (CC BY) license (http://crea-
tivecommons.org/licenses/by/4.0/).
Cosmetics 2021, 8, 50 2 of 18
of each model in safety testing of cosmetic products are discussed and novel technologies
capable of addressing these limitations are presented.
Figure 1. Overview of different alternatives to animal testing for safety assessment of cosmetic prod-
ucts and cosmetic ingredients. Assays in grey are not discussed in this review.
2. Regulatory Requirements for Cosmetics Safety Assessments
Overall Context
In Europe, the Cosmetic Regulation N°1223/2009 sets the framework for the safety of
any cosmetic product [1]. Although, many other geographical areas do not specify the
detailed documentation to establish their own frameworks, their regulations share the
common goal of ensuring safety of the final consumers.
Some ingredients must be included in so-called “positive” lists, for the ones having
specific functions (Annex VI for colorants, Annex V for preservatives, Annex V for UV filters).
An ingredient with such a function should then comply to the requirements of the given An-
nex. Some ingredients are prohibited (Annex II) or restricted to particular uses (Annex III).
The origin of those regulatory limitations is mainly safety. In Europe, some of the
ingredients are evaluated by the SCCS (Scientific Committee on Consumer Safety), which
publishes its opinion with safe conditions of use, before the ingredient is listed in an an-
nex. The SCCS publishes opinions based on the evidence presented to it, combined with
guidance. That is helpful, rather than spelling out the prescriptive demand for strict ad-
herence to precise regulatory “guidelines”. The European committee regularly provides a
guidance for the evaluation of the safety of ingredients [2,3]. In the USA, the CIR (Cos-
metic Ingredient Review), established from a trade association (currently the PCPC) with
the support of the FDA prioritizes and assesses cosmetic ingredients, generally consider
groups of similar substances based on chemical families or plant-derived ingredients. The
CIR’s report does not include the risk assessment.
All regulated ingredients must have a favorable opinion of the SCCS, such as the
recent ones on resorcinol, for its use in hair dyes [4], propylparaben as preservative (up-
dated opinion discarding any concern related to endocrine disruption) [5] or octocrylene
as UV filter (other update related to endocrine disruption) [6].
Cosmetics 2021, 8, 50 3 of 18
However, the committee can also give its opinion on substances for non-regulated
uses (titanium dioxide in inhaled products [7] or aluminum in lipsticks [8]).
Some publications can also be available from national authorities, related to particu-
lar concern for a country (example of phenoxyethanol in France [9]), or specific investiga-
tions allowing a better management of the risk, as in the case of “technically unavoidable
concentrations” of heavy metals, studied in Germany [10].
Transversal regulations can have consequences on the safety of the substances used
in cosmetic products: the CLP Regulation (classification, labelling and packaging of sub-
stances and mixtures) [11] of major importance for CMR (carcinogenic, mutagenic and
reprotoxic) substances. The carcinogenic, mutagenic, and reprotoxic substances are con-
sidered as the most dangerous substances; their harmonized classification in Europe is
rarely based on epidemiological information (asbestos, benzene, etc.) and more generally
based on experimental results in animals (musk xylene, Disperse Yellow 3, etc.). The An-
nex XVII of REACH can be of major importance for a very limited number of substances:
D4 (cyclopentasiloxane) and D5 (cyclotetrasiloxane) are prohibited silicones in rinsed
products above 0.1% (under entry 70 of the Annex XVII of REACH for restrictions) [12].
This decision is not triggered by toxicological properties but by their fate in the environ-
ment: these are the PBT and vPvB effects (for Persistent, Bioaccumulative and Toxic, Very
Persistent, Very Bioaccumulative).
The list of SVHC (substances of very high concern) includes substances based on con-
cern regarding reprotoxicity, carcinogenicity, endocrine disruption or effects for the envi-
ronment, PBT or vPvB.
Those programs are somehow linked to each other (the general concern of endocrine
disruption justified a call for data from the European Commission to revise the opinions
of the SCCS (e.g., Benzophenone-3, octocrylene, benzyl salicylate…) in the past two years.
Substances restricted by an Annex
When the SCCS receives a mandate from the European Commission to assess the
safety of a substance for a regulated function, the opinion is based on the analysis of the
scientific dossier submitted by the industry.
The scientific opinion considers each endpoint, including local tolerance (skin irrita-
tion, phototoxicity when relevant), genotoxicity, systemic toxicity including reprotoxicity
and sub-chronic/chronic toxicity. Characterization of dermal absorption is essential to cal-
culate the SED (systemic exposure dose).
The exposure of the substance is considered as its expected concentration in cosmetic
products, either in one given product or in several products, when a broad use is expected,
as it would be for a preservative.
Substances not restricted by an Annex
Any other substance, ingredient, or impurity has the obligation of being safe for the
consumer, based on the toxicological profile, as required by the Annex I and Guidelines
[13], using regularly updated data from supplier or literature.
There are two points of view: the one of the supplier of the ingredient and the one of
the Responsible Person for a cosmetic product using the ingredient (the Responsible Per-
son being the legal entity in Europe responsible for the product, generally the manufac-
turer). They do not have the same regulatory obligations. However, they should have the
same purpose: consumer safety.
Any supplier of a cometic ingredient, such as any company which manufactures and
markets a substance in the European Union, must register its substance according to the
annual tonnage.
Even if the intrinsic toxicity of a substance is independent from its production, the
number of toxicological results required in a REACH registration dossier depend on the
annual tonnage. Highly toxic substances and substances of low toxicity have the same
requirements (but important concern should be taken into account among the program of
SVHC: substances of very high concern). No toxicological data are requested for
Cosmetics 2021, 8, 50 4 of 18
substances registered below 1 to 10 tpa (ton per annuum) and increasing information is
required to be submitted with increasing tonnage bands.
For tonnage of 10–100 tpa (Annex VII): toxicological requirements include data for in
vitro skin irritation/ corrosion, in vitro eye irritation, skin sensitization, in vitro gene mu-
tation in bacteria, acute toxicity, and short-term toxicity (28 days).
At 10 to 1000 tpa (Annex VIII): toxicological requirements include data for in vitro muta-
genicity study in mammalian cells or in vitro micronucleus study, in vitro gene mutation in
mammalian cells, in vivo skin irritation, in vivo eye irritation, possibly testing proposal for in
vivo genotoxicity, acute toxicity, and screening for reproductive/developmental toxicity.
At 100 to 1000 tpa (Annex IX) following endpoints are added: the sub-chronic toxicity
(90 days), prenatal developmental toxicity in one species, and extended one-generation
reproductive toxicity.
Finally, above 1000 tpa (Annex X) a long-term repeated dose toxicity (≥ 12 months) if
triggered, with developmental toxicity in a second species, extended one-generation re-
productive toxicity, and carcinogenicity.
Several reviews of these methods are available; we can cite a very recent one focused
on cosmetic and REACH regulations [14]. Particularly, assessing the safety of the con-
sumer should include the assessment of any potential regarding endocrine disruption, but
this endpoint is not required in the REACH registration dossiers. The inclusion of such
criteria by the CLP Regulation could change things in the future.
It is then important to realize that for ingredients produced below 10 to 1000 tpa, no
information is available about the DNA damage (micronucleus test), and below 100 tpa,
neither any sub-chronic toxicity nor any information on the full cycle of reproduction is
known. A supplier of cosmetic ingredients should then think about the need of the cos-
metic brands (Responsible Persons in general) who need to prove the safety of each ingre-
dient.
The cosmetic brand (the Responsible Person) is the one responsible of the product.
Studies can be made on the product, to confirm a good acceptability in humans. It is
mostly to confirm the absence of eye and skin irritation, by in vitro test and other comple-
mentary tests in humans (the grail being the use test in normal conditions of use, to con-
firm the absence of objective irritation and absence of signs of discomfort). The tests for
photo-toxicity or skin sensitization are rarely performed. It should be reminded that the
Human Repeat Insult Patch Test (HRIPT) is non ethical and usually the historical data are
significantly poor from a statistical point of view using a small size panel [15,16]. How-
ever, the new in vitro tests for skin sensitization are quite promising, particularly if they
can cover multiple Key Events of the Adverse Outcome Pathway, and if they can be ap-
plied to the finished product. Both the SENS-IS and Genomic Allergen Rapid Detection
(GARD) assays analyze the genomic response of the cells to the exposure of the substance
or the product to predict sensitization, including its potency [17], with GARD assay being
able to quantify the dose–effects relationship, thus providing a good perspective for its
use in quantitative risk assessment [18]. Any test done on the finished product, as those
two last ones, and the tests made on eleuthero-embryo from fish or amphibians discussed
in this article are of particular relevance, since a large part of the risk assessment on the
product in based on individual data of substances.
The major part of the safety then relies on the toxicological data of the substances.
The toxicological results can come from the supplier, when they have a REACH registra-
tion dossier, or when they voluntary produce additional in vitro data. It can also be exist-
ing data from literature or in silico predictions Quantitative Structure-Activity Relation-
ship (QSARs) or read-across. The safety assessor, working with the Responsible Person,
makes a comprehensive search of existing toxicological information to write the toxico-
logical profile of the ingredient, and possibly identify any data gaps. Pragmatically, toxi-
cological profiles of ingredients often lack some information. Among the most current
data gaps includes following endpoints: skin sensitization, DNA damage, chronic toxicity,
and dermal absorption. With one exception, in vitro assays exist for all these endpoints,
Cosmetics 2021, 8, 50 5 of 18
most of them with OECD guidelines, or with good results of validation. When it is chosen
not to perform the test (data waiving), a rationale is absolutely needed as justification. In
vitro micronucleus test is one of the missing test which has no reason to be lacking, since
an in vitro OECD test exists for a long time. Probably there is a misunderstanding of the
Responsible Person who might not realize that it is absolutely complementary to the in
vitro mutagenicity test in bacteria, since both tests investigate two independent types of
abnormalities of DNA, both predictive of cancer.
In some cases, a reliable in silico prediction, with one, or even better, consensus from
several complementary software, can waive or replace such tests. This solution can be
cheaper than testing and the rationale can be robust. In silico predictions are also a good strat-
egy when associated to partially concluded results, such as the in vitro mutagenicity test. This
test is not sufficient to investigate genotoxicity, but a QSAR prediction can provide a good
orientation before performing the in vitro micronucleus assay, to better understand the poten-
tial of a substance to induce DNA damage. Such approaches are widely accepted for the reg-
ulatory assessment of pharmaceutical impurities under ICH M7 guideline [19].
Currently, with other methods gathered in the so-called NAMs (New Approach
Methodologies), read-across is a major tool to predict the systemic toxicity of a substance
in the absence of any animal testing. Finding structural analogues, selecting them based
on relevant criteria, and predicting an endpoint-specific toxicity based on the results for-
merly obtained with those analogues is both a very ethical way to use existing data, and
provides a relevant and reliable solution for predicting sub-chronic/chronic toxicity and
reprotoxicity [20]. This parameter is one of the criteria of toxicokinetic (absorption, distri-
bution, metabolism, and excretion; ADME) which should be better used in the future to
enhance the application of NAMs [21].
Last but not least, although dermal absorption could help calculating a precise mar-
gin of safety, it is hardly investigated. This rare information is of equal importance in the
calculation of the MoS (Margin of Safety) as the systemic NOAEL (or Point of Departure)
and the exposure. Generally unknown, it is, by default, estimated to 50% according to the
Notes of Guidance from the SCCS. For some substances, a “very low rate” can justify to
avoid investigating systemic toxicity. The mathematical modeling of dermal absorption is
an important field of research [22] but no robust model is currently available. Some mod-
els identified good predictivity but were limited to small substances below 300 Da [23]. A
recent preliminary retrospective analysis of the ingredients with opinions of the SCCS
showed that physicochemical properties of the substance can differentiate the ones with
low and high dermal absorption (the threshold being at 2%) [24].
This article does not detail the requirement on impurities, which also deserve the
attention of the safety assessor. CMR impurities are prohibited, but we can recommend to
pay attention to any impurity, since this could have adverse effects.
3. Genotoxicity Assessment of Cosmetic Products
In the second part of the 20th century, many research teams [25] have developed dif-
ferent kind of tests based on different mechanisms showing direct DNA damages (DNA
adduct, unscheduled DNA synthesis, DNA repair chromosomal aberrations), to detect
direct DNA reactive substances that alter DNA and therefore the genetic code. In the 70s,
Bruce Ames developed the most famous bacterial Reverse Mutation test, the “Ames test”
[26]. The most relevant mutagen tests were quickly taken into account by regulatory au-
thorities to identify genotoxic substances in cosmetics [27] and also by cosmetics compa-
nies for optimization of the methods and refined cosmetics ingredients [28]. Test battery
strategies for genotoxicity evaluation have been issued by regulatory agencies and guide-
lines are published by OECD.
In the safety assessment of cosmetic ingredients, the assessment of genotoxic poten-
tial is crucial. The SCCS 10th Revision [2] recommended to use an in vitro battery of two
tests. One test for the evaluation of the potential for mutagenicity: bacterial reverse muta-
tion test (OECD 471) Ames test [29] and a second in vitro micronucleus test (OECD 487)
Cosmetics 2021, 8, 50 6 of 18
[30] for the evaluation of chromosome damage (clastogen and aneuploidy). The combina-
tion of both tests allowed the detection of all relevant genotoxic carcinogens [31,32]. The
test system should be exposed to the test item both in the absence and in the presence of
a metabolic activation system (S9-fraction from the livers of rats treated with Aroclor 1254
or a combination of phenobarbital and β-naphthoflavone) [33].
The mutagenicity: bacterial reverse mutation test should be performed in the first
instance, as the result could lead to an end of the project. The nature of test item has an
impact on the method that should be used and consequently on the expected result. For
pure compounds, if using the Ames test, the structure of the test item should be consid-
ered. Thus, depending on the nature of the test article the metabolic activation system
should be adapted (SCCS/1532/14). For nanoparticles, a gene mutation test in mammalian
cells (OECD 476), or mouse lymphoma assay (OECD 490) should be performed instead of
the Ames test. For complex mixtures such as biological compounds or plant extracts the,
presence of amino acid producing a feeder effect could be observed. In this case “treat and
wash” method [34,35] could be used. The presence of flavonoids i.e., quercetin or
kaempferol in plant extract could lead to increases in the number of the revertant colonies
[36], in such case the quantification of this kind of substances in the plant extract is essen-
tial to explain the results obtained [37,38].
Before engaging into the second genetic toxicology test, an in-silico assessment
(Quantitative Structure-Activity Relationship QSAR, DEREK, Multicase, or Compound
Toxicity Profile) is useful to predict the clastogen potential of the pure chemical in accord-
ance with the stringent quality criteria and the validation principles laid down by the
OECD 487 [39]. In case of alert or when the prediction is out of domain, the micronucleus
test should be performed following OECD 487 guideline. Recently, this technic has been
refined in order to avoid a “false positive”. The cell lines (V79, CHO and CHL) were con-
sistently more susceptible to cytotoxicity and micronucleus induction than p53-competent
cells and are therefore more susceptible to giving misleading positive results. These data
suggest that a reduction in the frequency of misleading positive results can be achieved
by careful selection of the mammalian cell type for genotoxicity testing [40].
One of the strengths of the cosmetics industry is the exclusive use of in vitro tests and
consequently in vitro micronucleus has been also adapted to high-throughput technology,
i.e., with only 10 milligrams, a micronucleus test is performed by flow cytometry [41] or using
automated slide image analysis systems [42] and with double labelling telomere and centro-
mere the distinction between aneugen and clastogen effect could be done [43,44].
When the results from both tests are clearly negative, the test item has no mutagenic
potential. On the other hand, when the results from both tests are clearly positive, the test
item is considered as being mutagen. In both cases further testing is not mandatory.
When one of the two tests gives a positive result, the test item is considered an in
vitro mutagen. Further testing is required for excluding mutagen (clastogen) potential of
the test item assessed.
Equivocal results for mixture plant extract can be obtained in particular in micronu-
cleus test when excessive osmolarity, pH or excessive concentration leads to a high level
of cytotoxicity [43,44]. In this case the toolbox for further evaluation in WoE (weight of
evidence) approach is described in the SCCS recommendation:
“The comet assay [45] in mammalian cells or on 3D-reconstructed human skin [46] is
a tool which can support a WoE approach in the case of a positive or equivocal gene mu-
tation test in bacteria or mammalian gene mutation test.”
This battery of tests leads to the identification of substances named initiators. They and
their metabolites are DNA reactive carcinogens. In the theory of carcinogenesis, a second kind
of substances are the promotors, they are non-genotoxic carcinogens. The SCCS/1602/18 (2018)
recommends using the cell transformation assay (CTA) [47,48] as an alternative new test to in
vivo carcinogenesis studies, to detect genotoxic and non-genotoxic carcinogens.
Progress in the knowledge of stem cells makes it is possible to propose new biological
models to be closer to the in vivo exposure such organoid models [49] or for a screening
Cosmetics 2021, 8, 50 7 of 18
approach such as the ToxTracker
®
model. The total blood is also a robust alternative, as it
is easily available and extensively studied. In silico, and in the next future, AI (artificial
intelligence), for analysis and prediction will be increasingly relevant, with the concept to
build a “finger print of genotoxicity” as for drug in pharmaceutical companies.
4. Skin Sensitization Assessment of Cosmetic Products
Skin sensitizers are chemicals that have the intrinsic potential to induce a state of
hypersensitivity in humans, that upon repeated topical exposure may result in the devel-
opment of allergic contact dermatitis (ACD). Sensitization involves the activation of an
adaptive immune response and the priming of immunological memory, and once ac-
quired, it is often a chronical condition, and elicitation of clinical symptoms can only be pre-
vented by avoiding exposure to the inducing agent (see for example [50] for an excellent re-
view). Proactive identification and evaluation of skin sensitization potential is therefore of cen-
tral importance for safety evaluation of chemicals and represents a key toxicological endpoint
among regulatory authorities across multiple industries, and not least for cosmetics, where
the intended route of exposure often is via dermal application [51].
Before a new cosmetic ingredient is placed on the European market, evaluation of its
safety profile, including the assessment of skin sensitization hazards and potency is man-
datory. Following the revision of Annex VII of the REACH regulation [52], as well as the
transformation of the cosmetic directive into a regulation (EC1223/2009) [1], traditional
animal models, such as the Guinea Pig based assays (GPMT or the Buehler test) [53] or
the murine Local Lymph Node Assay (LLNA) [54], are no longer allowed to meet the
information requirements for substances exclusively intended for use in cosmetic prod-
ucts. To this end, a plethora of New Approach Methods (NAMs), such as in chemico and
in vitro methods, have been validated and incorporated into official test guidelines by the
OECD, serving as viable replacements for animal studies. These methods are designed to
target individual Key Events (KE) in the Adverse Outcome Pathway (AOP) for skin sen-
sitization [55], which recapitulates the most important key mechanistic events that are
required for the development of skin sensitization. Currently, three technical Test Guide-
lines (OECD TG 442 C, D and E) describe a total of seven such methods, including the KE1
based Direct Peptide Reactivity Assay (DPRA) and the Amino acid Derivative Reactivity
Assay (ADRA) [56], the KE2 based assays KeratinoSens and LuSens [57], and the KE3
based assays h-CLAT, U-SENS, and the IL-8 Luc assay [58]. According to the current test-
ing paradigm, these methods should not be considered as stand-alone assays, but rather
in the context of a tiered testing strategy, a so-called defined approach (DA), where a fixed
data integration procedure is used to arrive at a final classification, based on the readout
from several NAMs. Currently, several DAs have been described for hazard identification
of skin sensitizers, and their individual components, data integration procedures (DIPs),
and performances have been summarized in [59]. Importantly, based on the empirical
data from this publication, accuracies of the proposed DAs, ranging between 75.6% to
85.0%, were superior to that of the LLNA (74.2%) for predicting human skin sensitization
hazard. In addition to the current OECD adopted assays, several alternative and innova-
tive assays are in the process of being validated and adapted as official TGs [60], some
showing predictive performances similar to the proposed DAs, also when considered as
stand-alone assays [61]. Thus, skin sensitization testing is an ever-moving target, and to
provide guidance to testing and safety evaluation to the cosmetic industry, the Scientific
Committee on Consumer Safety (SCCS) publishes the “Notes of Guidance for the Testing
of Cosmetic Ingredients and Their Safety Evaluation” [2], ensuring that testing can be per-
formed in compliance with EU cosmetic legislations.
Despite the above-mentioned progress to replace animal experimentation, more
work is still needed to address certain limitations with current NAM-based strategies. For
example, it has been recognized that certain chemicals of interest to the cosmetic sector
may be difficult to test in the conventional OECD validated assays [62]. Such limitations,
as far as they have been identified, are described in individual TGs, and may include
Cosmetics 2021, 8, 50 8 of 18
constraints with testing of hydrophobic ingredients, pre-pro haptens, and complex sub-
stances, including natural extracts where the ingredient of concern is often present in mi-
nute concentrations within a complex mixture. Novel state-of-the-art scientific methods
currently in the OECD Test Guideline Program (TGP) and under evaluation for official
TG adaption [60], such as the Genomic Allergen Rapid Detection (GARD) assay [63,64],
which is based on the measurements of a biomarker signature of genes associated with
immunologically relevant pathways to the sensitization process, have shown promise to
address some of these limitations. For example, the GARD assay is compatible with a va-
riety of different solvents that can be applied to increase bioavailability of a Test Item [65],
and a protocol is also available for testing of solid materials, such as medical devices, using
both polar and non-polar extraction vehicles in compliance with ISO-10993:12 [66]. Such
findings may prove potentially useful also for cosmetic-related test items, such as UVCBs
or natural extracts with limited solubility in conventional assay solvents, such as DMSO
or water. Furthermore, several 3D-models based on reconstructed human epidermis
(RHE) have also been developed to address some of the solubility limitations (reviewed
in [62]). The majority of these assays have a clearly defined readout of established bi-
omarkers (e.g., IL-18), while others are less transparent. In a recent publication evaluating
the performance of a selection of such models, the majority of the RHE-based assays
showed similar, or slightly improved performances (dependent on the specific RHE-as-
say) to the best performing OECD validated assay, the h-CLAT assay, when investigating
a limited set of “difficult-to-test” substances in comparison to human reference data [63],
demonstrating that such assays may comprise a viable source of information within a
weight-of- evidence approach for testing within this chemical domain.
In addition to the limited applicability domain, the most obvious limitation of the
current OECD validated assays is likely that they have only been validated for skin sensi-
tization hazard identification, and not for assessment of sensitizing potency, which is a
critical component for risk assessment of cosmetic ingredients when used in consumer
products. Skin sensitization is a threshold phenomenon, and a quantitative risk assess-
ment (QRA) of individual ingredients aims to define a maximum dose of the chemical not
inducing sensitization (referred to as the NESIL value) [67,68]. The general procedure for
QRA, involving a continuous prediction of skin sensitizing potency as a point of departure
(POD), which is subsequently adjusted by applying uncertainty factors, has been de-
scribed for fragrances [67], and its applicability to general cosmetic ingredients is cur-
rently being discussed. Development of NAM based strategies also for continuous assess-
ment of skin sensitizing potency for use as point-of-departure in the QRA is ongoing, and
examples include the DA-based Artificial Neural Network Model for Predicting LLNA
EC3 [69], as well as the recently proposed GARDskin Dose-Response model [18,70].
Finally, as novel NAM-based methods are developed to replace traditional animal
models for assessment of cosmetic ingredients, the ultimate arbiter of the capacity of these
tests to protect human health must be evaluated based on how well they correlate with
reliable information on the skin sensitizing activity of chemicals in humans, and not how
well they recapitulate the weaknesses of the “gold” standard animal tests, irrespective of
their historical consideration as valid and adapted OECD methods. For chemicals of hith-
erto unknown sensitization potential, the preclinical evaluation of cosmetic ingredients
using the NAM strategies described above is an essential and important first step to en-
sure the safety profile of cosmetics, but also as described in [71], post-market surveillance,
often referred to as cosmetovigilance, will remain an important part to ensure that the use
of cosmetic ingredients, as well as their concentration in formulated products remain safe
to the consumers.
Cosmetics 2021, 8, 50 9 of 18
5. Endocrine Properties Assessment of Cosmetic Products
On the 13 December 2017 the European Parliament adopted scientific criteria to de-
fine endocrine disruptors which came into force for plant protection products and bio-
cides in 2018 [72]. This has been a major step towards the future implementation of similar
criteria for regulation of cosmetics in Europe. Despite the discrepancies due to the partic-
ular context of cosmetics, a few lessons relating to endocrine assessment strategies have
been learnt from experience.
Adopted criteria for endocrine disruptors are closely related to the WHO definition
of 2012 [73]. An endocrine disruptor is defined by three main criteria: its endocrine mode
of action, its capacity to cause an adverse effect, and the plausible link between this endo-
crine activity and the related adverse outcome.
Regulatory authorities require datasets to permit a conclusive assessment on the dis-
ruptive capacity of an endocrine active sample. However, for cosmetic ingredients this
will be difficult as availability of comprehensive endocrine test systems is very limited
without accessing animal experimentation. Therefore, alternative models will be required
to overcome this difficulty that can provide data which will contribute to safety of cos-
metics for the endocrine system in an ethical manner.
Since 2002, experts representing OECD member countries have published test guide-
lines dedicated to endocrine assessment of chemicals. These internationally acknowledged
methods are listed, and their proper usage is described within the OECD Guidance Document
150 [74]. According to this document, adversity should be assessed (using laboratory animals)
to achieve a conclusive assessment of an endocrine disruptor. OECD validated methods cover
so far EATS (Estrogen, Androgen, Thyroid, and Steroidogenic) endocrine pathways, for which
specific adverse physiological outcomes have been characterized.
It could be argued that the absence of endocrine activity excludes the need for inves-
tigating physiological adversity. This opens a possible testing strategy for an ethical cos-
metic approach: using a battery of validated in vitro/embryonic models to cover all major
modes of action of endocrine disruptors on EATS pathways. Cellular-based assays using
tumoral cell lines, allow the assessment of the transactivation capacity estrogen (OECD
TG 455) [75] or androgen (TG 458) [76] receptors, as well as disruption of steroidogenesis
(TG 456) [77]. Nevertheless, performing all these assays independently will not mimic the
interaction of these mechanisms occurring in vivo and many modes of actions are not
covered by in vitro tests such as disruption of 5-alpha reductase endocrine target to coun-
teract alopecia [78]. The complexity and crosstalk of endocrine pathways as well as the
number of mechanisms involved often leads to false positive or false negative results us-
ing cellular models [79,80]. Identifying an endocrine disruptor boils down to elucidating
an adverse outcome pathway and requires a complete endocrine system as a model.
As indicated by the SCCS guidance notes [3], due to the conservation of endocrine
mechanisms across vertebrate species data provided by “some ecotox tests may be informa-
tive for the assessment of the endocrine activity of a compound in humans”. This is of great
value as the additional information provided by ecotoxicological tests significantly increases
the weight of evidence available for endocrine assessment of cosmetic ingredients.
Embryos of aquatic vertebrates provide ethical and useful models to assess endocrine
activity of cosmetic ingredients or products in a whole endocrine system. In 2019, the
OECD published the first eleuthero–embryo-based test to assess Thyroid activity, Test
Guideline 248 (XETA) [81]. Eleuthero–embryo defines early life stages post-hatch which
still depend on maternally deposited energy reserves making them eligible for cosmetic
testing according to the EU definition of a laboratory animal [82]. This first eleuthero–
embryonic model for measuring thyroid activity paved the way for the development of a
series of embryonic models derived from fish and amphibians bearing fluorescent re-
porter constructs integrating hormonal responsive elements.
Among assays in the OECD process of validation, the EASZY and REACTIV assays
are dedicated to measuring estrogenic activities. These models carry specific targets to
reveal the brains response to estrogens (EASZY) [83] and estrogenic control over
Cosmetics 2021, 8, 50 10 of 18
reproduction (REACTIV) [84]. Further, it is also included in the OECD work program on
endocrine disruptors and in the EFSA/ECHA guidance document [85] on endocrine dis-
ruptor assessment is the RADAR [86] assay which measures androgenic activities related
to male reproductive behaviors.
These embryonic models allow the detection and quantification of endocrine activi-
ties by the quantification of fluorescence. Even if these in vitro aquatic models are not
necessarily predictive of the effects in humans, they make it possible to detect endocrine
activity and constitute a predictive screening tool.
The criteria adopted by the EU for the assessment of endocrine disruptors are hazard
based. These criteria were implemented within plant protection product and biocide reg-
ulations in 2018. Weight of evidence provided by models that identify modes of action
and related adverse outcomes have replaced risk assessment for the classification of en-
docrine disruptors. However, for the assessment of cosmetic ingredients, implementation
of these hazard-based criteria without the use of laboratory animals remains a challenge.
Despite this, some solutions are available to provide more realistic exposure scenarios
whilst avoiding the use of regulated life stages of laboratory animals. Linking the selection of
test concentrations for hazard assessment to a range of daily doses of a compound or product
could be one approach for screening cosmetics. Recent advances in the development of eleu-
thero–embryonic tests systems also provide options for semi-quantitative assessment of en-
docrine activity in a whole endocrine system. Allowing the identification of ingredients, ex-
tracts, or preparations, which would require more in-depth investigation.
Data provided by embryonic models and cellular assays will be a great source of
knowledge to feed into the development of in silico models. Our ultimate aim should be
to develop in silico models of each endocrine pathway, and one day perhaps a computa-
tional model of a complete vertebrate endocrine system.
6. Assessment of Dermal Absorption of Cosmetic Products
Assessment of dermal absorption is a crucial aspect of cosmetic product and ingredi-
ent safety, as opposed to drugs, which almost always enter the body in other ways. In
vitro dermal absorption studies are the gold standard method for skin pharmacokinetic
evaluation and are suitable to predict the expected dermal absorption by humans.
The purpose of the dermal absorption testing, also known as dermal penetration or
percutaneous penetration, is to provide a measurement of the absorption or penetration
of a substance through the skin barrier and into the skin.
Detailed guidance on the performance of in vitro skin absorption studies is available
(OECD 2004, 2011, 2019), [87–89]. In addition, the SCCNFP (Scientific Committee on Cos-
metics and NonFood Products) adopted a first set of “Basic Criteria” for the in vitro as-
sessment of dermal absorption of cosmetic ingredients back in 1999 and updated in 2003
(SCCNFP/0750/03) [90]. The SCCS updated this Opinion in 2010 (SCCS/1358/10) [91]. A
combination of OECD 428 guideline with the SCCS “Basic Criteria” (SCCS/1358/10) is con-
sidered to be essential for performing appropriate in vitro dermal absorption studies for
cosmetic ingredients.
Dermal absorption studies are conducted to determine how much of a chemical pen-
etrates the skin, and thereby whether it has the potential to be absorbed into the systemic
circulation. Therefore, knowledge of dermal absorption phenomena is essential for:
Safety issues: the presence of systemic test item may lead to systemic adverse effects,
the quantities absorbed is taken into consideration in toxicological risk assessment to
extrapolate human exposure and calculate the margin of safety (MoS); and
Therapeutic aspects: the quantities penetrated can be taken into consideration to pre-
dict the therapeutic concentration at the target sites in skin tissue.
In vitro dermal absorption studies are applied in different sectors and for different
purposes:
Formulation Screening: for selection of lead candidate formulation;
Cosmetics 2021, 8, 50 11 of 18
Bioequivalence: to determine if the new product has the same degree of dermal ab-
sorption as reference product. In vitro dermal absorption assay was recently used to
demonstrate bioequivalence, and the results of the comparison were accepted by the
FDA in connection with the marketing authorization for Lotrimin Ultra cream [92];
Cosmetics and consumer products: Dermal absorption rate is part of the toxicological
profile of any ingredient. Almost always provided for any submission to the SCCS,
the in vitro dermal absorption studies can then be part of the safety assessment of a
cosmetic product;
Pharmaceutical products: in vitro dermal absorption studies are part of safety and
efficacy assessment of topical products;
Chemical/agrochemical: in vitro dermal absorption studies are part of safety assess-
ment purposes. With respect to pesticides, the results of the in vitro dermal absorp-
tion studies alone are accepted for pesticides risk assessment purposes in the Euro-
pean Union and other countries.
Different types of formulations can be assessed through in vitro dermal absorption
studies: creams, gels, ointments, suspensions, foam, patches, aqueous, solvent, hair dyes,
shampoo, foundation, moisturizer, cleansers, soaps, sunscreen, etc.
When conducting in vitro dermal absorption study, skin sample is placed between
two chambers (a donor chamber and a receptor chamber) of a Franz-type diffusion cell in
a way such that the stratum corneum is facing the donor compartment where the formula-
tion to be examined is applied, while the dermis is touching receptor compartment.
Human skin samples are usually obtained from patients undergoing plastic surgery.
Abdominal skin is most convenient, due to the large areas that may be available. Carefully
handled frozen human skin are suitable for testing the passive permeation of chemicals,
when skin viability and metabolic activity were not being investigated [93]. However, for
studies requiring the presence of viable epidermal tissue, such as investigations of drug
transporters [94–98] or skin metabolism [96], fresh skin samples are required.
There are considerable differences in skin absorption across different body sites, at-
tributed to stratum corneum thickness, hydration, and lipid composition [99–103]. To re-
duce variability, it is recommended to use split-thickness skin. Full-thickness skin is cut
to approximately 500–750 µm using a dermatome. Quality of skin samples have to be
checked at the beginning of the experiment. This is done by measuring transepidermal
water loss (TEWL) indicative of barrier integrity.
A finite dose of tested product is applied on the skin surface and incubation is done
at 32 °C. The permeation rate of a test item from the donor compartment through the skin
into the receptor is determined by measuring the amount of drug in skin samples and in
receptor fluid. Different analytical methods can be used to quantify the amount of test
item in the samples.
Different analytical methods can be used to quantify concentration of test substance
in different skin compartments according to physicochemical properties of the test sub-
stance such as lipophilicity, molecular weight, charge, and concentration of the test sub-
stance: liquid chromatography–tandem mass spectrometry (LC-MS/MS); inductively cou-
pled plasma–tandem mass spectrometry (ICP-MS/MS), liquid chromatography with UV
detection (LC-UV) or fluorescence detection (LC-Fluo), liquid scintillation counting (LSC)
for radiolabelled compound, and imaging approaches, e.g., epifluorescence or confocal
microscopy in the case of fluorescent molecules or matrix-assisted laser desorption–mass
spectrometry imaging (MALDI-MSI) [104].
In vitro dermal absorption assay is very operator-dependent, and care needs to be
taken especially when handling skin samples and when removing the excess of formula-
tion. The success of the assay is equally dependent on the development and validation of
sensitive analytical methods to quantify the amount of test substance in the samples.
One of the main challenges is how to measure dermal absorption in babies and infant
skin necessary in cosmetic ingredient safety assessments. It is recognized that babies, in-
fants, and children represent a distinct subpopulation for risk and safety assessments, and
Cosmetics 2021, 8, 50 12 of 18
routinely considered the greater skin–surface area to body–mass ratio in children when
performing cosmetic ingredient safety assessments [105]. Systemic exposures in babies
and infants are generally assumed to be greater than in older children and adults. On one
side, the percutaneous absorption could be higher because of the immaturity of the skin as a
barrier to absorption (higher pH of the skin yields decreased barrier function and increased
risk of irritation), particularly onto the nappy area. On the other side, the greater body–surface-
area to body–mass ratio of babies and infants compared with older children and adults, math-
ematically induces high amounts in mg/kg bw/w for a similar quantity of product [106–110].
Modifications of existing in vitro skin penetration protocols to evaluate the potential for higher
absorption from topically applied products are needed. The use of compromised skin repre-
sents a good alternative to mimic underdeveloped barrier function as in premature infant skin.
Compromised skin can be achieved by different procedures, e.g., tape stripping, micronee-
dling device, abrasive skin preparation pad, or even iontophoresis [111–113].
7. Skin and Eye Irritation Assessment of Cosmetic Products
Assessment of skin and eye irritation potential of an ingredient or formulation is an
important part in cosmetic ingredient safety assessments.
Dermal irritation is defined as the production of reversible damage of the skin, fol-
lowing the application of a test substance for up to 4 h (OECD 404) [114]. Eye irritation is
defined as the occurrence of changes in the eye following the application of a test sub-
stance to the anterior surface of the eye, which are fully reversible within 21 days of ap-
plication (OECD 405) [115].
Skin and eye irritation are assessed using reconstructed human tissue-based test
methods. Commercially available 3D-models based on reconstructed human epidermis
(RhE) are used for skin irritation testing (OECD test Method 439) [116] and 3D-model
based on reconstructed human cornea-like epithelium (RhCE) is used for eye irritation testing
(OECD Test Method 492) [117]. It should be noted that there are different in vitro models that
address serious eye damage and/or identification of chemicals not triggering classification for
eye irritation or serious eye damage [3], but we will only focus on RhCE model.
The overall design 3D-models based on reconstructed human tissues mimics the bi-
ochemical and physiological properties of the upper layers of the human skin and eye.
RHE is a skin model composed of living human keratinocytes which have been cul-
tured to form a multi-layered, highly differentiated epidermis. The model consists of
highly organized basal cells and includes a functional skin barrier with an in vivo-like lipid
profile.
RhCE is a corneal model composed of living human cells which have been cultured
to form a multi-layered, differentiated corneal epithelium. The model consists of highly
organized basal cells which progressively flatten out as the apical surface of the tissue is
approached, analogous to the normal human in vivo corneal epithelium.
In both models, the cells are both metabolically and mitotically active, and release many
of the pro-inflammatory agents (cytokines) known to be important in irritation and inflamma-
tion. Reconstructed human tissues are grown on special platforms at the air-liquid interface.
The test item is applied directly to the tissue surface, providing a good model of “real
life” exposure. The endpoint used in both RhE and RhCE test methods is the cell-mediated
reduction of MTT (3-(4,5)-dimethyl-2-thiazolyl-2,5-dimethyl-2H-tetrazolium bromide)
into a blue formazan salt that is quantitatively measured after extraction from the tissues.
A second endpoint can be used to increase sensitivity is the measurement of interleukin-
1α (IL-1α) production.
If the viability is greater than 50% (RhE) or 60% (RhCE), the test item is classified as
Non-Irritant (no-label or UN GHS No Category).
If the viability is below or equal to 50% in the case of RhE model, the test item is
classified Irritant (UN GHS Category 2).
If the viability is below or equal to 60% in the case of RhCE, no prediction can be
made, and further testing may be required.
Cosmetics 2021, 8, 50 13 of 18
So far, neither a single in vitro assay nor a testing battery has been validated as a
standalone replacement for the in vivo test. New test systems are under development using
stem cells. These could generate new alternatives for in vitro ocular toxicity testing [118].
8. Conclusions
The total number of experiments in animals only slightly decreased in Europe be-
tween 2015 and 2017. It changed from 9.59 million animals to 9.39 million, when it was
11.5 million in 2011. Animals are mainly used for research (69%) and then for regulatory
purpose (23%). In 2017, 61% of the experiments in animals were for medical products for
humans, 15% for veterinary products, 11% for industrial chemicals. Moreover, the report
of the European Commission identifies a concern about the use of animals for endpoints
where alternative methods exist (irritation, skin sensitization).
Despite the marketing ban of cosmetic ingredients and cosmetic products tested in
animals, there is still debate on this issue. From a regulatory point of view, the position of
the European Agency is clear and has been clarified (“Clarity on interface between
REACH and the Cosmetics Regulation”). No cosmetic product is currently tested in animals
in Europe. The cosmetic ingredients can have former results obtained from toxicological tests
in animals. These results can be obtained after the animal testing ban, but only if required by
another regulation (food, pharmaceutical, or even REACH, considering the obligations of
safety of the workers). If cosmetics are the only use of a substance, all in silico and in vitro tests
will then be encouraged to demonstrate the safety. However, for a toxicologist, it remains a
huge challenge to guarantee the absence of risk based on the current available methods. All
so-called New Approach Methodologies, using AOPs, IATAs, or Defined Approaches will be
the foundation of the safety for future new ingredients [119].
A wide range of in vitro models for safety testing of cosmetic products and cosmetic
ingredients has been developed and adopted in test guidelines. There is still an increasing
need, largely driven by regulatory authorities and industry, to develop in vitro models to
predict carcinogenicity, repeat dose toxicity and reproductive toxicity, for which no alter-
native in vitro methods are currently available.
Author Contributions: Conceptualization, H.O.-P., C.B., F.F., A.F., A.C.H., G.F.L. and J.-P.T.; validation,
H.J, M.B. and I.M.; data curation, M.B., H.F., I.M., A.F., C.B. and G.F.L.; writing—original draft prepara-
tion, M.B., C.B., F.F., A.F., A.C.H., H.J., G.F.L. and H.O.-P.; writing—review and editing, M.B., C.B., A.F.,
F.F., G.F.L. and H.O.-P.; supervision, J.-P.T. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: There is no data supporting reported results generated during the study.
Acknowledgments: The authors thank Dr. Faizan Sahigara for assistance with the language in this
article.
Conflicts of Interest: The authors declare no conflict of interest in this work.
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... Therefore, it is necessary to conduct safety testing as one of the requirements for preparation before it is marketed to the wider public. Irritation testing can be carried out using various methods, including the Draize, acute dermal, and patch tests (Barthe et al. 2021). ...
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... accessed on 14 March 2025). For this reason, studies on alternative methods have been conducted, and in recent years, three-dimensional (3D) skin models consisting of fibroblast and keratinocyte cell cultures have been successfully applied in cosmetic research [17]. Preliminary toxicological evaluation of new active compounds and herbal extracts can also be accomplished in skin cell lines such as keratinocytes and fibroblasts [18,19]. ...
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Use of three-dimensional (3D) tissue equivalents in toxicology has been increasing over the last decade as novel preclinical test systems and as alternatives to animal testing. In the area of genetic toxicology, progress has been made with establishing robust protocols for skin, airway (lung) and liver tissue equivalents. In light of these advancements, a “Use of 3D Tissues in Genotoxicity Testing” working group (WG) met at the 7th IWGT meeting in Tokyo in November 2017 to discuss progress with these models and how they may fit into a genotoxicity testing strategy. The workshop demonstrated that skin models have reached an advanced state of validation following over 10 years of development, while liver and airway model-based genotoxicity assays show promise but are at an early stage of development. Further effort in liver and airway model-based assays is needed to address the lack of coverage of the three main endpoints of genotoxicity (mutagenicity, clastogenicity and aneugenicity), and information on metabolic competence. The IWGT WG believes that the 3D skin comet and micronucleus assays are now sufficiently validated to undergo an independent peer review of the validation study, followed by development of individual OECD Test Guidelines.
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INTRODUCTION Five-alpha reductase (5-AR) deficiency was first identified by Imperato-McGinley and Walsh as the cause of pseudohermaphroditism in two separate studies. The discoveries led to the development of finasteride (inhibitor of type 2 isoenzyme of 5-AR) and dutasteride (inhibitor of type 1 and type 2 isoenzymes of 5-AR. Both drugs have been proven effective for the treatment of benign prostatic hyperplasia and improve voiding symptoms, reduce the risk of urinary retention and the need for prostate surgery. Five-alpha reductase inhibitors 5-ARIs have been demonstrated to be chemopreventive agents and reduce the risk of prostate cancer, although the risk of selecting out or mediating higher grade prostate cancer remains uncertain. A lower dose of finasteride has been shown to be effective in the treatment of male pattern baldness. Materials and methods: A Medline search was performed using mesh terms, benign prostatic hypertrophy, prostate cancer, male pattern baldness, female and 5-AR. Results: The Prostate Long Term Efficacy and Safety Study (PLESS) was a randomized double-blind study that established that finasteride resulted in a 22% increase in maximum flow rate and a 19% decrease in prostate volume. Further studies demonstrated that finasteride caused a significant reduction in the risk of the need for surgery and urinary retention in a 4 year period. Additional studies showed similar beneficial results with dutasteride. The potential benefits of 5-ARIs as chemopreventive agents were examined in the Prostate Cancer Prevention Trial (PCPT) and the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) studies. In the 7 year PCPT trial, 18.4% of the finasteride group developed prostate cancer compared to 24.4% in the placebo group. In the 4 year REDUCE trial, there was a 22.8% reduction of prostate cancer at the conclusion of the study. Despite the reduction of prostate cancer in both the PCPT and REDUCE trials, each study showed an increased risk of prostate cancer in the treatment arms. The explanation for these observations remains an area of investigation. Low dose finasteride has also been used successfully for the treatment of male pattern baldness. Conclusions: The use of 5-ARIs has been a major advance in urologic clinical practice. Urologists should be familiar with the underlying pharmacology of 5-ARIs as well as the clinical indications for their use.
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