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Kohl, Kajal, Al-Kahal, Surma, Tiro, Tozali, or Kwalli: By Any Name, Beware of Lead Poisoning

Many people may be unaware of the lead poisoning risk, in adults and children, from an avoidable source: traditional eye cosmetics containing kohl, kajal, al-kahal, surma, tiro, tozali, or kwalli.

The following information is intended to answer questions people may ask about these products and their dangers:

What are these products made of?

Kohl, kajal, al-Kahal, surma, tiro, tozali, and kwalli often contain high levels of lead. For example, lead, usually in the form of lead sulfide, sometimes accounts for more than half the weight of kohl products. Kohl products may also contain a variety of other materials, such as aluminum, antimony, carbon, iron, and zinc compounds, as well as camphor and menthol.[1, 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14] A tiro product linked to lead poisoning in an infant was found to consist of 82.6% lead.[15]

What are the effects of lead poisoning?

The risks associated with exposure to lead are especially serious for children. Among the effects associated with high levels of lead exposure are anemia, kidney problems, and neurological damage that may include seizures, coma, and death. Even at relatively low levels, chronic exposure to lead may lead to learning and behavior problems. The Centers for Disease Control (CDC) has set a blood lead level of 5 micrograms per deciliter (µg/dL) in children as the reference level at which CDC recommends initiating public health actions (see CDC information under "Lead").

Are kohl and similar products directly linked to increased levels of lead in children?

Yes. FDA is aware of instances of kohl-related lead poisoning in children in the U.S. A number of studies have shown that children exposed to kohl and similar products have increased levels of lead in their blood.[3, 4, 9, 11, 15]

How are children exposed to kohl and similar products?

In some cultures, it is common for parents to apply these products to the eyes of infants and children. Infants of mothers who use these products sometimes have elevated levels of lead in their blood.[9, 11] Also, some people traditionally paint a newborn's umbilical stump with kohl powder, supposedly for medicinal reasons.[3, 4]

Unlike some sources of exposure to lead, this one is easily avoidable by not using kohl and similar products on your children or yourself, and keeping them out of your home.

If someone in my family has been exposed to one of these products, what should I do?

Here are two important steps to take against exposure to kohl and similar products:

  • Stop using the product immediately and be especially careful to protect children from further exposure. 
  • Ask a healthcare provider to test children as well as pregnant or nursing women for lead poisoning if they have used the product.

You will receive further recommendations based on the results of your laboratory tests.

Are these products legal in the United States?

No. Here’s why:

FDA has identified kohl, kajal, surma, and similar materials as illegal color additives as defined in the law (Federal Food, Drug and Cosmetic Act, section 201(t)). Under this law, color additives must be approved by FDA and listed in the color additive regulations before they are allowed in cosmetics or any other FDA-regulated products. To be FDA-approved, they must be safe for the intended use.

None of these materials have been approved by FDA and listed in the color additive regulations. This means that their use in cosmetics or any other FDA-regulated products is against the law. To learn more, see "Color Additives and Cosmetics."

FDA has an import Alert in effect for eye area cosmetics that declare kohl, kajal, or surma on their labels, not only because they appear to contain high levels of lead, but also because of other labeling violations. For example, some of these products have been falsely labeled as having "FDA approval." Such products are subject to detention and refusal of admission at U.S. ports of entry. 

Where do these products come from?

These products have been popular in much of the world since ancient times, particularly in parts of Africa, the Middle East, Pakistan, and India. Kohl and similar products now sometimes appear in specialty markets catering to individuals from the above regions. More recently, tiro, tozali, and kwalli products have come from Nigeria.[15] Despite being illegal in the United States, these products may be imported by individual users, for example, in personal luggage. These products also have been sold by mail order on some websites.

Where can I learn more about lead poisoning?

One useful resource is the Lead Poisoning Prevention Program at the Centers for Disease Control and Prevention.

References

  1. Al-Ashban RM, Aslam M, Shah AH. Kohl (surma): A toxic traditional eye cosmetic study in Saudi Arabia. Public Health. 2004 Jun; 118(4):292-8
  2. Al-Hazzaa SA, Krahn PM. "Kohl: a hazardous eyeliner." International Ophthalmology, 1995; 19(2):83-8.
  3. Alkhawajah AM. "Alkohl use in Saudi Arabia: Extent of use and possible lead toxicity." Tropical Geographical Medicine, 1992 Oct; 44(4):373-7.
  4. Al-Saleh I, Nester M. DeVol E, Shinwari N, Al-Shahria S. "Determinants of blood lead levels in Saudi Arabian schoolgirls." International Journal of Environmental Health, 1999 Apr-Jun; 5(2):107-14.
  5. Hardy AD, Vaishnav R, Al-Kharusi SS, Sutherland HH, Worthing MA. "Composition of eye cosmetics (kohls) used in Oman." Journal of Ethnopharmacology, 1998 Apr; 60 (3):223-34.
  6. Hardy AD, Walton RI, Myers KA, Vaishnav R. Availability and chemical composition of traditional eye cosmetics ("kohls") used in the United Arab Emirates of Dubai, Sharjah, Ajman, Umm Al-Quwain, Ras Al-Khaimah, and Fujairah. J Cosmet Sci. 2006 Mar-Apr; 57(2):107-25.
  7. Jallad KN, Hedderich HG. Characterization of a hazardous eyeliner (kohl) by confocal Raman microscopy. J Hazard Mater. 2005 Sep 30; 124(1-3):236-40.
  8. Lekouch N, Sedki A, Nejmeddine A, Gamon S. "Lead and traditional Moroccan pharmacopoeia." Science of the Total Environment, 2001 Dec. 3; 280(1-3):39-43.
  9. Nir A, Tamir A, Nelnik N, Iancu TC. "Is eye cosmetic a source of lead poisoning?" Israel Journal of Medical Science, 1992 Jul; 28(7):417-21.
  10. Parry C, Eaton J. "Kohl: a lead-hazardous eye makeup from the Third World to the First World." Environmental Health Perspectives, 1991 Aug; 94:121-3.
  11. Rahbar MH, White F, Agboatwalla M, Hozhbari S, and Luby S. "Factors associated with elevated blood lead concentrations in children in Karachi, Pakistan." Bulletin of the World Health Organization. 2002, 80(10):769-775.
  12. Goswami K. “Eye cosmetic 'surma': hidden threats of lead poisoning.” Indian Journal of Clinical Biochemistry. 2013 Jan; 28(1):71-3
  13. Kervegant M, Glaizal M, Tichadou L, Hayek-Lanthois M, de Haro L. “Daily use of kohl as the origin of possible lead poisoning.” La Presse Médicale, 2012 Feb; 41(2):203-4. [article in French].
  14. De Caluwé JP. “Lead poisoning caused by prolonged use of kohl, an underestimated cause in French-speaking countries.” Journal Français d’Ophtalmologie. 2009 Sep;32(7):459-63. Erratum in: J Fr Ophtalmol. 2010 Jan;33(1):75.
  15. Centers for Disease Control, Morbidity and Mortality Weekly Report (MMWR). “Infant lead poisoning associated with use of tiro, an eye cosmetic from Nigeria--Boston, Massachusetts, 2011.” August 3, 2012 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6130a3.htm.  

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