Kohl and Lead Poisoning: What Every Parent Should Know

Does traditional kohl actually contain lead?

Yes, and the concentrations found in laboratory testing are often very high. Traditional kohl, known across the Arab world as kuhl, surma in South and Central Asian communities, and tiro in parts of West Africa, is commonly made from galena, which is lead sulfide. A 2005 study published in the Journal of Hazardous Materials that used confocal Raman microscopy to characterise kohl samples found lead sulfide as a primary component. The lead content in traditional preparations has been measured in some studies at over 80 percent by weight.

A 2024 review in Pediatrics examined traditional eye cosmetics and cultural powders as sources of lead exposure and confirmed that galena-based kohl remains in widespread use and continues to produce elevated blood lead levels in children who are exposed to it regularly. The review noted that testing of imported products in several countries found high lead content even in products sold commercially and labelled as cosmetics.

Not every product called kohl contains lead. Some modern cosmetic products marketed under the name kohl use alternative pigments such as carbon black or iron oxide, which do not carry the same risk. The difficulty is that there is no reliable way to tell by looking at a product whether it contains lead sulfide or a safer alternative, particularly if the product was purchased informally or brought from overseas.

How does lead enter the body from kohl?

Lead from kohl enters the body through several routes. The skin around the eye is thin and well-supplied with blood vessels, which allows absorption directly into the circulation. When applied to the inner lid margin or conjunctiva, which is the lining of the eye itself, lead particles dissolve in the eye fluid and are absorbed through the mucous membranes. Infants also frequently rub their eyes and then put their hands in their mouths, which adds an ingestion route on top of the absorption route.

The same pathways apply when kohl is applied to other parts of the body, as happens in some traditions where a small amount is placed on the navel or scalp of a newborn. These are areas of high skin permeability in a newborn, and the blood lead levels in infants exposed through these routes have been measured at levels well above the action thresholds used in most countries.

Adults who apply kohl to themselves are also at some risk, particularly if they use it frequently or apply it to the inner eyelid, but the risk to a developing infant brain is qualitatively different and far more serious. Lead does not stay in the blood indefinitely: it eventually deposits in bone and, in children, in developing brain tissue. That deposition is where the permanent damage occurs.

What does lead exposure do to a child?

There is no safe level of lead for a child's developing nervous system. This is the conclusion reached by the WHO, the CDC, and every major paediatric body worldwide. Lead interferes with the development of neurons and the connections between them. At high levels it causes seizures, coma, and death. At the lower levels typically associated with kohl exposure, the effects are less dramatic but permanent: reductions in IQ, shortened attention span, impulsive behaviour, difficulty learning to read and write, and problems with hearing.

A 2021 systematic review in The Lancet Planetary Health of blood lead levels in low- and middle-income countries found elevated levels across multiple regions, with children in the Middle East and North Africa among those with measurable exposures. The sources varied, including old paint, leaded petrol residues in soil, and traditional cosmetics including kohl. The review estimated that tens of millions of children in these regions have blood lead levels above the threshold at which cognitive effects are expected.

The insidious feature of lead poisoning at these levels is that it is silent. A child with a blood lead level of 10 micrograms per decilitre does not look ill, does not complain of anything specific, and will not receive a diagnosis unless someone tests for it. By the time symptoms are obvious, the exposure and the damage have been going on for a long time.

What are the symptoms of lead poisoning in children?

At the levels associated with kohl exposure, most children have no obvious symptoms at all. When symptoms do appear, they are general and easily attributed to other causes: irritability, loss of appetite, difficulty sleeping, stomach aches, and constipation. These are the same complaints that accompany many ordinary childhood illnesses, which is why lead poisoning goes undetected for so long in children who are exposed to it regularly.

At higher exposure levels, symptoms become more specific: persistent vomiting, severe stomach pain, muscle weakness, loss of coordination, and seizures. These levels are rare from cosmetic exposure alone but can occur if a child has multiple simultaneous lead sources, such as kohl plus exposure to old lead paint in an older house, plus contaminated soil in the yard. In communities where kohl use is common, other lead sources may also be present.

A 2012 CDC report documented an infant in Boston who developed lead poisoning from a traditional cosmetic product brought from Nigeria. The infant had no other lead source identified. The blood lead level found was well above the CDC's reference value of 3.5 micrograms per decilitre. This case illustrates that the route is real and that the harm occurs in otherwise normal home environments.

How is lead exposure tested and treated?

The test is a blood lead level, measured from a small blood sample. It is a straightforward test available in most hospital laboratories and larger clinics across the region. The current reference value used by the CDC is 3.5 micrograms per decilitre, which means a result above this is a reason for investigation and action, not necessarily an emergency, but worth taking seriously.

If a child's blood lead level is elevated, the most important step is removing the source. If kohl has been identified as the source, stopping its use immediately is essential. If the level is high, the doctor may recommend chelation therapy, which is a medical treatment that binds lead in the blood and helps the body excrete it. Chelation is used at higher levels and is not a substitute for removing the source.

If you have used kohl on your child and are concerned, ask your paediatrician to order a blood lead level. The test is inexpensive, requires a small blood sample, and provides a clear number. You do not need to wait for symptoms.

What is the cultural significance of kohl and how can it be respected safely?

Kohl has deep cultural and religious meaning across the Arab world and beyond. Its use is mentioned in traditional Islamic medicine and has been practised for many centuries for purposes that include protecting the eyes from bright light and the evil eye, as well as for aesthetics. The intent behind applying it to a newborn is one of love, blessing, and connection to tradition. This cultural reality matters and it is not dismissed here.

The safety concern is specific to lead-containing preparations applied to infants and young children. The same practice carried out using a product confirmed to be lead-free carries a different risk profile. Some modern antimony-based products, labelled as cosmetic kohl, contain antimony sulfide rather than lead sulfide. Antimony at the amounts in cosmetics is less acutely toxic than lead, though it is not without risk.

The safest approach for infants is to avoid all eye cosmetics until the child is old enough that the eye area is not being treated as an application site. For older children and adults who wish to use kohl as a cosmetic, choosing products from manufacturers who can demonstrate their product is lead-free, or who are regulated by a credible cosmetics authority, substantially reduces the risk. In practice this means looking for products manufactured in countries with cosmetics regulations that test for heavy metals, rather than products brought informally across borders.

Safer alternatives for those who value the practice

For parents who wish to mark the birth of a child with a symbolic gesture in the kohl tradition, there are several approaches that carry no lead risk. A very small touch of a lead-free commercial eyeliner pencil, not applied to the eye itself but as a symbolic dot, uses a product where the manufacturer is accountable to cosmetics regulations. Some parents choose to perform the gesture on themselves rather than the infant as a symbolic act that honours the tradition without the physiological exposure.

For older children who want to use a cosmetic eyeliner, products produced by established cosmetics brands sold in licensed pharmacies or department stores and subject to regulatory oversight in the country of manufacture are substantially safer than traditional preparations bought in markets or brought from abroad. The product should list its ingredients clearly. If the ingredient list includes galena, lead sulfide, or does not list ingredients at all, do not use it.

For adults, the risk from kohl is lower than for infants, but it is not zero, particularly with frequent use. Choosing regulated cosmetics over traditional preparations that cannot be tested is still the safer approach, and the cosmetic result is comparable.

Where to get a blood lead test in the region

Blood lead testing is available at hospital laboratories in major cities across the Arab world, though access in smaller towns and rural areas varies. In Saudi Arabia, Jordan, Egypt, and the UAE, paediatric outpatient clinics can order the test. In countries where testing is not locally available, a referral to a hospital with a more comprehensive laboratory service is the practical route.

You do not need to present with symptoms to request a blood lead test for a child who has had regular kohl exposure. Frame the request to the doctor as a precautionary check in a child who has had repeated exposure to a cosmetic that may contain lead. Most paediatric doctors familiar with the practice will understand the request immediately.

If the test returns elevated, the doctor should guide the next steps, which depend on the level found. Mild elevation requires source removal and a repeat test in a few months to confirm the level is falling. Higher levels require closer follow-up and, in some cases, treatment. Keep a record of the test result in the child's health records, because lead levels inform developmental monitoring for years.

Sources

• Hore P, Sedlar S: Traditional Eye Cosmetics and Cultural Powders as a Source of Lead Exposure, Pediatrics, 2024
• McMichael JR, Stoff BK: Surma eye cosmetic in Afghanistan: a potential source of lead toxicity in children, European journal of pediatrics, 2018
• Centers for Disease Control and Prevention (CDC): Infant lead poisoning associated with use of tiro, an eye cosmetic from Nigeria--Boston, Massachusetts, 2011, MMWR. Morbidity and mortality weekly report, 2012
• Jallad KN, Hedderich HG: Characterization of a hazardous eyeliner (kohl) by confocal Raman microscopy, Journal of hazardous materials, 2005
• Ericson B, Hu H, Nash E et al: Blood lead levels in low-income and middle-income countries: a systematic review, The Lancet. Planetary health, 2021
• Nir A, Tamir A, Zelnik N et al: Is eye cosmetic a source of lead poisoning?, Israel journal of medical sciences, 1992