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Contact Allergy Caused by Fragrance Mix and Myroxylon Pereirae (Balsam of Peru) – a Retrospective Study

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Contact Allergy Caused by Fragrance Mix and Myroxylon Pereirae (Balsam of Peru) – a Retrospective Study Coll. Antropol. 35 (2011) 1: 83–87 Original scientific paper Contact Allergy Caused by Fragrance Mix and Myroxylon pereirae (Balsam Of Peru) – A Retrospective Study Petra Tur~i}1, Jasna Lipozen~i}2, Vi{nja Milavec-Pureti}2 and Sandra Marinovi} Kuli{i}2 1 University of Zagreb, Faculty of Pharmacy and Biochemistry, Department of Pharmacology, Zagreb, Croatia 2 University of Zagreb, Zagreb University Hospital Center, University Department of Dermatology and Venereology, Zagreb, Croatia ABSTRACT Because of their widespread use, fragrances are among the most common causes of contact allergic dermatitis, second only to nickel. During a five-year period 3,065 patients with contact dermatitis were patch tested using a specific mix of fragrances. 509 (16.6%) patients were allergic to the fragrance mix, while 258 (8.4%) patients exhibited an allergic reac- tion to Myroxylon pereirae (balsam of Peru). Between those 509 patients, 157 were patch tested with eight individual substances contained in the fragrance mix: cinnamal, cinnamyl alcohol, eugenol, isoeugenol, geraniol, hydroxycitro- nellal, alpha-amyl cinnamal and Evernia prunastri (oak moss). The most frequent allergens were isoeugenol 57.9% (91/157), eugenol 55.4% (87/157), cinnamyl alcohol 34.4% (54/157) and Evernia prunastri (oak moss) 24.2% (38/157). There were 62 patients (39.5%) who exhibited an allergic reaction to both the fragrance mix and Myroxylon pereirae (bal- sam of Peru). The results prove the importance of avoiding allergens in daily life, especially in industrial and cosmetic products. In order to prevent ACD, better cooperation between industry and dermatologists is needed. Key words: fragrances, contact allergic dermatitis, Myroxylon pereirae (balsam of Peru), fragrance mix, fragrance ingredients Introduction Allergy to fragrance materials was recognized at the shown that eugenol and cinnamal are capable of inhibit- beginning of the 20th century. It was first noticed in sca- ing contact dermatitis and contact urticaria reaction. 4–6 bies patients treated with topical balsams containing fra- This is called the quenching phenomenon . Fragrances grance materials1. Fragrances consist of many natural or are small-molecular-weight compounds of different che- chemical ingredients, as shown by results published in mical structures. All of the pure chemicals in the fra- 1975 by Fisher, who composed a long list of fragrance in- grance mix are phenolic in structure, except geraniol and gredients and suggested concentrations for epicutaneous hydroxycitronellal, which are terpenes. They can cause tests2. In 1977 Larsen developed a fragrance mixture reactions by means of several mechanisms. For instance, (FM) which contained 8 ingredients (cinnamyl alcohol, reactive compounds bind directly to proteins, which are cinnamal, alpha-amyl cinnamal, eugenol, isoeugenol, ge- subsequently processed and presented to specific T lym- raniol, Evernia prunastri (oak moss) absolute and hydro- phocytes7,8 and nonreactive compounds gain their im- xycitronellal); the result was a screening patch-test sub- munogenicity only after metabolic activation through ox- stance for fragrance allergy3. Today we know that a idation of the parent compound9. Enzymes involved in single perfume may contain over 300 individual ingredi- this reaction are cytochrome P450 enzymes (CYPs)10. ents. For this reason, detection of allergy to one specific Next to nickel, fragrances are the most common cause of component is a difficult and complex matter. Another contact allergic dermatitis (CAD), which is a form of de- problem is presented by false negative/positive reactions layed-type hypersensitivity reaction mediated by T lym- to fragrance ingredients. For example, some studies have phocytes11,12. Allergy to fragrances can present a serious Received for publication May 20, 2009 83 P. Tur~i} et al.: Allergy to Fragrances, Coll. Antropol. 35 (2011) 1: 83–87 clinical problem for the population, especially for atopic substances generally related to cinnamon, vanilla, and individuals, because of widespread use of fragrance ma- clove fragrances and flavorings. Hjorth established that terials in creams, lotions, detergents and other personal MP contained many potential allergens and it was con- and household products. In our study we also involved sidered the most important patch test indicator for fra- Myroxylon pereirae – balsam of Peru (MP) because it is grance allergy for a long time13–15. Many patients with a the third most prevalent allergen and has a rather wide- history of fragrance allergy may react to MP16,17. Con- spread use. MP is a sticky aromatic liquid that comes comitant reactions between FM and MP are well-known from cutting the bark of the Myroxylon pereirae tree, na- phenomena15,18–20 because five of the FM components tive to Central America. It contains a mixture of many (cinnamyl alcohol, cinnamal, alpha-amyl cinnamal, euge- TABLE 1 CHARACTERISTICS OF FRAGRANCE INGREDIENTS Fragrance ingredient Chemical formula Structural formula Characteristics White to slightly yellow solid, OH odor of hyacinth cinnamyl alcohol C9H10O Phenol structure Cinnamomum spp. O A clear yellow to greenish yellow liquid with a pungent spicy note cinnamal C9H8O Phenol structure Cinnamomum spp O Synthetic essential oil, intense alpha-amyl cinnamal C14H18O odor of jasmine Phenol structure Clear to pale yellow oily liquid, O powerful spicy odor of clove and a HO pungent taste eugenol C10H12O2 Allyl chain-substituted guaiacol, phenol structure Eugenia aromaticum; Eugenia caryophyllata O Colorless to light yellow-brown HO transparent liquid, odor of clove, isoeugenol C10H12O2 weaker than eugenol Phenol structure Nutmeg oil and ylang ylang oil Synthetic floral fragrance, sweet hydroxycitronellal C10H18O2 fresh odor of lily of the valley HO OH Non-cyclic primary alcohols Clear to pale-yellow oil insoluble in water geraniol C10H18O Non-cyclic monoterpene alcohol OH Rose oil; palmarosa oil; citronella oil Green to greenish-white and rough thalli – dry; dark ol- ive-green to yellow-green and rubbery thalli – wet Evernia prunastri Evernia prunastri Contains: atranorin, (oak moss) chloroatranorin, everic acid, usnic acid, resin acid, dehydroabietic acid, abietic acid, diethyl phthalate, alpha-terpineol, cedrane, linalool etc. 84 P. Tur~i} et al.: Allergy to Fragrances, Coll. Antropol. 35 (2011) 1: 83–87 nol, and isoeugenol) are found in MP. Therefore, a posi- 80,00% tive patch test to MP often indicates fragrance allergy. 70,00% The aim of the present study was to determine the in- 60,00% cidence of fragrance-induced CAD using a specific fra- grance mix. Patch testing according to the International 50,00% Contact Dermatitis Research Group (ICDRG) system 40,00% was conducted during 2001–2005 in Zagreb, Croatia. 30,00% 20,00% Materials and Methods 10,00% Patients 0,00% 2001 2002 2003 2004 2005 TOTAL A total of 27,815 patients with suspected CAD were 2001–2005 included in the study. The epicutaneous (patch) tests and cinnamyl alcohol cinnamal eugenol isoeugenol related data collection were carried out during a period of a-amyl cinnamal geraniol hydroxycitronellal oak moss five consecutive years (2001–2005) at the Allergy Clinic Fig. 1. Positive patch test reactions to individual components of of the Department of Dermatology and Venereology, Zag- the fragrance mix during a five-year period. reb University Hospital Center and School of Medicine, Zagreb, Croatia. FM, and 258/3,065 (8.4%) were positive to MP (Table 2). The fragrance series was tested on 157 (age range7–78; Materials mean age: 40.51; median: 40) patients: 113 female (71.97%; Fragrances, Myroxylon pereirae (balsam of Peru) and age range 7 – 74; mean age: 38.95; median: 39) and 44 fragrance mix 8% in petrolatum (consisting of cinnamal male (28.0%; age range 10 – 78; mean age: 44.52; median: (cinnamal) – 1%; cinnamyl alcohol – 5%; alpha-amyl 48.5), who were chosen out of the 509 patients positive to cinnamal – 5%; eugenol – 5%; isoeugenol – 5%; geraniol – fragrance allergens. The most frequent allergens were 5%; hydroxycitronellal – 1%; and Evernia prunastri (oak isoeugenol 57.9% (91/157), eugenol 55.4% (87/157), cin- moss) absolute – 2%) (Table 1), used for patch testing, namyl alcohol 34.4% (54/157) and Evernia prunastri (oak were obtained from the Immunology Institute in Zagreb, moss) 24.2% (38/157). There were 39.5% (62/157) pa- Croatia. tients positive to both MP and FM (Figures 1 and 2). Pos- itive reactions to both MP and FM were calculated ac- Methods cording to year: 2001 – 30% were patch test positive to Patch-test allergens were applied on the patients’ up- FM and MP. From 10 subjects allergic to FM, 3 were also per back with 2-day occlusion. According to the Interna- positive to MP (3/10); 2002 – 53.33% (16/30); 2003 – tional Contact Dermatitis Research Group (ICDRG) sys- 46.15% (18/39); 2004 – 31.3% (9/29); 2005 – 32.65% tem, the tests were read 48 and 72 hours after their (16/49). application21,22. The test results were interpreted using the following scale: negative reaction (0); macular ery- thema (?); erythema/in filtration and possibly papules Discussion (1+); erythematous papules and/or vesicles (2+); spread- Fragrances are ubiquitously used in cosmetics such as ing blisters and/or crust with ulceration (3+); and irri- creams, lotions, medication, household and industrial tant reaction (IR); whereby 1+, 2+ and 3+ were consid- products. They are also very common ingredients in food 21 ered positive allergic reactions . Statistical analysis was and paints23. Such
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