Colophony (Rosin) Allergy: More Than Just Christmas Trees

Clinical AND Health Affairs

Colophony (rosin) allergy: more than just Christmas trees

BY LINDSEY M. VOLLER, BA; REBECCA S. KIMYON, BS; AND ERIN M. WARSHAW, MD

Colophony (rosin) is a sticky resin derived from pine trees and a recognized cause of allergic contact dermatitis (ACD), a type IV hypersensitivity reaction.1 It is present in many products (Table 1) and is a common culprit of allergic reactions to adhesive products including adherent bandages and ostomy devices. ACD to colophony in pine wood is less common although has been reported from occupational exposures,2 as well as consumer contact with wooden jewelry, furniture, toilet seats, and sauna furnishings.3 We present a patient with recurrent contact dermatitis following exposure to various wood products over the course of one year.

Case Description samples of the pine Christmas A 34-year-old otherwise healthy man pre- tree from the previous season. sented with a one-year history of intermit- Final patch test reading on day tent dermatitis associated with handling 5 demonstrated strong or very pine wood products. His first episode strong (++ or +++) reactions to occurred after building shelves using colophony, abietic acid, abitol, spruce-pine-fir (SPF) lumber. Symptoms pine sawdust, Nerdwax®, and began with immediate burning of the skin his Christmas tree (Figure followed by a vesicular, weeping dermatitis 3). He also had doubtful (+/-) three days later on the forehead (Figure 1), reactions to wood tar mix forearms (Figure 2) and legs. He received FIGURE 1 (containing pine) and several oral prednisone from Urgent Care with Erythema and vesicle formation on the upper left forehead following fragrances. Propolis (bee glue), subsequent resolution. Later, he developed exposure to spruce-pine-fir lumber. white beeswax, yellow beeswax, a similar rash on his hands after handling TABLE 1 a pine Christmas tree, as well as on his nasal bridge after applying Nerdwax®, a Potential sources of colophony tacky substance used to prevent slippage Adhesives, bandages Inks (pen, ceramic, printing) of eyeglasses. Two weeks prior to presen- Chewing gum Laundry soaps tation to our clinic, he developed a facial and forearm dermatitis after assembling Cigarette filters and paper Leather cleaner and lubricant wooden furniture. He denied symptoms Cosmetics (particularly mascara) Linoleum, floor tile, carpet adhesive from bandages or adhesives or from per- Dental materials Medicated creams and ointments sonal care products. The patient worked as Depilatory, hair removal wax Ostomy devices a high school English teacher and had no Disposable diapers, sanitary napkins Paints, lacquers, varnishes occupational contact with wood. Glues for shoes, boots, and insoles Paper products Patch testing was performed to the Grip aids (e.g., gymnastics, rock climbing) Pine oil cleaner, pine/spruce sawdust 2019-2020 North American Contact Firewood, match tips, fireworks Polishes (shoe, floor, car, furniture) Dermatitis Group screening series, se- lected allergens on the plant/wood and Furniture/floor polishes, stains Rosin for shoes, string instruments emulsifier series, and multiple home items Hair spray, pomade Shoes, shoe polish, shoe wax including Nerdwax®, pine sawdust, and Hydrocolloid dressings Sunscreens

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TABLE 2 Examples of products with colophony-free alternatives13

PRODUCT TYPE COLOPHONY-FREE ALTERNATIVES Adhesive tapes Dermicel, Micropore, Scanpor Bandages BandAid Sheer Strips Diapers, feminine hygiene Cloth diapers and pads products Grip aids Chalk, Zeasorb powder Glues Elmer’s Glue-All Epilating wax Depilatory creams or lotions, sugar wax Grocery bags Plastic preferred over paper (rosin found in some recycled paper) Hydrocolloid dressings DuoDERM original wound dressing or Flexible Collodion USP Rosin (baseball, bowling) Talc Rosin (violin, viola) Super Sensitive Clarity Spectrum Hypoallergenic Violin/Viola Rosin Shoes Wesco boots, Crocs, Saucony, Servuc Injection Molded Footwear

uncommon and allergens other than Resulting dermatitis presents up to four 4,5 FIGURE 2 colophony may be causative. Prior case days following last exposure consistent Erythema, edema, and multiple clustered vesicles on reports of pine wood allergy have primar- with a type IV, delayed type hypersensitiv- the left dorsal hand and medial forearm following ily been noted among individuals with ity reaction (allergic contact dermatitis).2 exposure to spruce-pine-fir lumber. repeated occupational exposures (e.g., Our patient noted facial involvement three cabinet makers, carpenters, and sawmill days after wiping sweat from his brows coconut oil, and peppermint were nega- workers).6–8 Non-occupational allergy to while building shelves composed of pine tive; the reaction to Nerdwax® was attrib- colophony in finished wood products wood. uted to gum rosin, a form of colophony is exceedingly rare but has also been re- While the majority of ACD cases to (Figure 4). ported, usually in settings of routine or pine wood occur occupationally, most prolonged exposures such as with furni- cases of isolated colophony allergy are Discussion ture and wooden jewelry.3,9 Clinical symp- due to adhesives, plasters, dental materi- Allergic reactions to colophony are com- toms of pine wood allergy include derma- als, hair removal waxing products, and mon but are usually due to adhesive titis of body areas directly contacting pine, certain cosmetics, especially mascara.6,10 sources (e.g. bandages, shoe glue). ACD in addition to airborne facial patterns if Rosin is used as a grip aid for gymnasts, to colophony in pine wood is relatively exposure entails wood dust/shavings.2,3 baseball players, bowlers, and rock climb-

FIGURE 4 FIGURES 3A, B, AND C Positive (++) reaction demonstrated on ® Positive (++ or +++) reactions day five patch test reading to Nerdwax . ® demonstrated on day five patch test Nerdwax declares gum rosin in its reading to colophony, pine sawdust, ingredient label, along with beeswax, abietic acid, and abitol. coconut oil, and peppermint.

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ers. It is also used to coat violin bows. As seen in this case, some 5 Ingram JR, Gasson P, Hughes TM, Stone NM. A bum deal from wooden toilet seats: Reemergence of allergic contact dermatitis. Dermatitis. 2012. doi:10.1097/ individuals with colophony allergy also have difficulty with pine DER.0b013e31826f879c 11 trees and pine decorations (i.e., “Christmas tree allergy”). Three 6 Miranda-Romero A, Gonzalez-Lopez A, Esquivias JI, Bajo C, Garcia-Munoz M. Allergic contact dermatitis due to pine wood [5]. J Eur Acad Dermatology Venereol. main types of colophony exist—gum rosin (the most commonly 1999. doi:10.1016/S0926-9959(98)00104-4 used), wood rosin, and tall oil, with primary differences based on 7 Majamaa H, Viljanen P. Occupational facial allergic contact dermatitis caused the method of manufacturing.1 Main components of colophony by Finnish pine and spruce wood dusts. Contact Dermatitis. 2004. doi:10.1111/ j.0105-1873.2004.0426k.x include resin acids, largely abietic acid, and a smaller “neutral 8 Hinnen U, Willa-Craps C, Elsner P. Allergic contact dermatitis from iroko and pine fraction” consisting of dihydroabietic acid and dehydroabietic wood dust. Contact Dermatitis. 1995. doi:10.1111/j.1600-0536.1995.tb02080.x acid.10Although both unmodified and modified forms of col- 9 Gómez-Muga S, Ratón-Nieto JA, Ocerin I. An unusual case of contact dermatitis caused by wooden bracelets. Contact Dermatitis. 2009. doi:10.1111/j.1600- ophony have allergenic potential, modified colophony products, 0536.2009.01620.x 4 such as abitol, are strong sensitizers. Notably, fragrance and 10 Mauro M, Fortina AB, Corradin T, Marino A, Bovenzi M, Filon FL. Sensitization 12 to, and allergic contact dermatitis caused by, colophonium in north-eastern Italy in propolis (bee glue) are common cross-reactors to colophony. 1996 to 2016 with a focus on occupational exposures. Contact Dermatitis. 2018. Our patient reacted to several fragrances but propolis and bees- doi:10.1111/cod.13089 wax were negative. 11 Gether L, Gyldenløve M, Thyssen JP. Christmas tree dermatitis caused by colophonium allergy. Contact Dermatitis. 2017. doi:10.1111/cod.12798 This patient’s noted patch test reactions, in addition to relevant 12 Shi Y, Nedorost S, Scheman L, Scheman A. Propolis, colophony, and fragrance clinical exposures, aligned well with pine wood and colophony cross-reactivity and allergic contact dermatitis. Dermatitis. 2016. doi:10.1097/ allergies. He was likely sensitized to pine wood, colophony, and DER.0000000000000186 13 Scheman A, Hylwa-Deufel S, Jacob SE, et al. Alternatives for Allergens in the their derivatives through previous furniture assembly projects. 2018 American Contact Dermatitis Society Core Series. Dermatitis. 2019;30(2):87- Future avoidance of colophony-containing products, includ- 105. doi:10.1097/DER.0000000000000453 ing pine wood, was recommended, as well as wearing protective clothing when contacting pine wood and avoidance of pine sawdust, which could result in significant airborne exposures. He did not report any prior issues with bandages or adhesives; however, given his strong reaction to colophony, specific alternatives for tapes and wound dressings without colophony and rosin were provided (Table 2). He was also prescribed a three-week oral EMPLOYMENT OPPORTUNITIES prednisone taper to resolve remaining dermatitis; if systemic ste- roids are indicated, it is important to provide a three-week taper (rather than a three- or five-day course) to prevent rebound from partially treated ACD. Carris Health We present this case to raise awareness regarding the clinical is the perfect match presentation of colophony allergy from a pine wood source. As a type IV hypersensitivity reaction, ACD typically presents two to three days after the last exposure and lasts for three weeks. Avoid- Carris Health is a multi-specialty health network ance of products containing colophony, pine, and related deriva- located in west central and southwest Minnesota and tives is mainstay therapy. MM is the perfect match for healthcare providers who are Lindsey M. Voller, BA, is a clinical research fellow within the Department looking for an exceptional practice opportunity and a of Dermatology, Park Nicollet Health Services and a fourth-year medical high quality of life. student at the University of Minnesota Medical School. Rebecca S. Kimyon, BS, is a fourth-year medical student at the University of CURRENT OPPORTUNITIES AVAILABLE FOR BE/ BC PHYSICIANS Minnesota Medical School. Erin M. Warshaw, MD, is a professor in the Department of Dermatology, University of Minnesota, and co-director of IN THE FOLLOWING SPECIALTIES: the Contact Dermatitis Clinic, Park Nicollet Health Services. • Anesthesiology • Hospitalist • Orthopedic Surgery • Dermatology • Internal Medicine • Psychiatry • ENT • Nephrology • Psychology REFERENCES • Family Medicine • Neurology • Pulmonary/ • Gastroenterology • OB/GYN Critical Care 1 Downs AMR, Sansom JE. Colophony allergy: A review. Contact Dermatitis. 1999. • General Surgery • Oncology • Rheumatology doi:10.1111/j.1600-0536.1999.tb06178.x • Urology 2 Estlander T, Jolanki R, Alanko K, Kanerva L. Occupational allergic contact der- Loan repayment assistance available. matitis caused by wood dusts. Contact Dermatitis. 2001. doi:10.1034/j.1600- 0536.2001.044004213.x FOR MORE INFORMATION: 3 Huilaja L, Kubin ME, Riekki R. Contact allergy to finished woods in furniture and furnishings: A small allergic contact dermatitis epidemic to western red cedar in Shana Zahrbock, sauna interior decoration. J Eur Acad Dermatology Venereol. 2016. doi:10.1111/ Physician Recruitment jdv.12937 [email protected] (320) 231-6353 | carrishealth.com 4 Hausen BM, Mohnert J. Contact allergy due to colophony. (V). Patch test results with different types of colophony and modified-colophony products. Contact Dermatitis. 1989;20(4):295-301. http://www.ncbi.nlm.nih.gov/pubmed/2752740.

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