Limonene and linalool hydroperoxides review: Pros and cons for routine patch testing.

Limonene and linalool are among the most common fragrance terpenes used in everyday products. They are pre-haptens, forming hydroperoxides (Lim-OOHs, Lin-OOHs) upon oxidation and inducing frequent positive patch test reactions in patients with dermatitis, and yet they are not routinely tested in Europe. This review evaluates current patch testing with Lim-OOHs and Lin-OOHs by asking whether hydroperoxide patch testing is warranted, examining the difficulties or challenges related to reading and interpreting hydroperoxide patch test results with currently available material, and assessing their relevance. Studies are increasingly pointing to high percentages of positive reactions in patients consecutively patch tested with these oxidized products. An association between a positive clinical history and a strong patch test reaction has been described, but problems with doubtful/irritant reactions have also been reported. Considering the high frequency of relevant positive reactions, the incorporation of Lim-OOHs 0.3% and Lin-OOHs 1% in the baseline series may be justified. Since exposure, sensitization, and elicitation limits of Lim-OOHs and Lin-OOHs in the products still need to be better determined, an assessment of previous exposure, possible sensitizations, and reactions may help to improve the clinical assessment.

Contact allergy to haptens in the Swedish baseline series: Results from the Swedish Patch Test Register (2010 to 2017).

BACKGROUND: Allergic contact dermatitis has considerable public health impact and causative haptens vary over time. OBJECTIVES: To report the prevalence of contact allergy to allergens in the Swedish baseline series 2010 to 2017, as registered in the Swedish Patch Test Register. METHODS: Results and demographic information for patients tested with the Swedish baseline series in 2010 to 2017 were analysed. RESULTS: Data for 21 663 individuals (females 69%) were included. Females had significantly more positive patch tests (54% vs 40%). The reaction prevalence rates were highest for nickel sulfate (20.7%), fragrance mix I (7.1%), Myroxylon pereirae (6.9%), potassium dichromate (6.9%), cobalt chloride (6.8%), methylchloroisothiazolinone/methylisothiazolinone (MCI/MI; 6.4%), MI (3.7%), colophonium (3.5%), fragrance mix II (3.2%), and formaldehyde (3.2%). Myroxylon pereirae reaction prevalence increased from 5% in 2010 to 9% in 2017 and that for methyldibromo glutaronitrile from 3.1% to 4.6%. MCI/MI and MI reactions decreased in prevalence after 2014. Nickel reaction prevalence decreased among females aged 10 to 19 years. CONCLUSIONS: Nickel remains the most common sensitizing agent, with reaction prevalence decreasing among females younger than 20 years. The changes in MCI/MI and MI reaction prevalence mirrored those in Europe. The register can reveal changes in contact allergy prevalence over time among patients patch tested in Sweden.

Patch testing with purified and oxidized citronellol.

BACKGROUND: Citronellol is a commonly used fragrance terpene included in fragrance mix II. As with many other fragrance terpenes, citronellol is susceptible to autoxidation. Citronellol hydroperoxides are formed in large amounts and are the only oxidation products identified as sensitizers in oxidized citronellol. AIM: To compare frequencies of contact allergy to purified and oxidized citronellol and to investigate the pattern of concomitant reactions to fragrance markers of the baseline series, oxidized linalool, and oxidized limonene. METHODS: A total of 658 dermatitis patients were patch tested with purified and oxidized citronellol at 2.0%, 4.0%, 6.0%, and 1.0%, 2.0%, 4.0%, 6.0% petrolatum, respectively. The irritant properties of purified and oxidized citronellol were studied before patch testing. RESULTS: Few irritant reactions were observed in the pretest. Purified citronellol detected positive reactions in 0.15%-0.31% of patients, while oxidized citronellol detected positive reactions in 0.61%-4.5%. Among patients reacting to oxidized citronellol, 34%-50% showed concomitant reactions to fragrance markers of the baseline series and 75%-91% to oxidized linalool or oxidized limonene. CONCLUSION: Oxidized citronellol detects more cases of contact allergy than purified citronellol, and these cases are not all detected using fragrance mix II. Patch testing with oxidized citronellol will add to the tools in the diagnosis of fragrance allergy.

Can patch testing with methylchloroisothiazolinone/methylisothiazolinone be optimized using a new diagnostic mix? - A multicenter study from the Swedish Contact Dermatitis Research Group.

BACKGROUND: Methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) and methylisothiazolinone (MI) are tested to detect contact allergy to these isothiazolinones. OBJECTIVES: To study if an aqueous patch test preparation with MCI and MI in a mix of 0.015% and 0.2%, respectively, detects more contact allergies than the commonly used preparations of MCI/MI in 0.02% aq. and MI in 0.2% aq. METHODS: A total of 1555 patients with dermatitis in five Swedish dermatology departments were tested consecutively with MCI/MI 0.215% aq., MCI/MI 0.02% aq., and MI 0.2% aq. RESULTS: The share of contact allergy to MCI/MI 0.215% aq., MCI/MI 0.02% aq., and MI 0.2% aq. varied in the test centers between 7.9% and 25.9%, 3.2% and 10.3%, and 5.8% and 12.3%, respectively. MCI/MI 0.215% aq. detected significantly more patch-test positive individuals than both MCI/MI 0.02% aq. (P < .001) and MI 0.2% aq. (P < .001), as well as either one of MCI/MI and MI (P < .001). In the patients only reacting to MCI/MI 0.215% aq., 57.7% were recorded as having a dermatitis that was explained or aggravated by exposure to either MCI/MI or MI. CONCLUSION: The results speak in favor of replacing the preparations MCI/MI 0.02% aq. and MI 0.2% aq. with MCI/MI 0.215% aq. as the screening substance in the Swedish baseline series, which has been implemented in 2020.

Contact allergy to citral and its constituents geranial and neral, coupled with reactions to the prehapten and prohapten geraniol.

BACKGROUND: Citral is commonly used as a fragrance and flavor material and consists of the aldehydes geranial and neral. Citral is included in fragrance mix (FM) II. Geranial and neral have also been identified in autoxidation of geraniol, a fragrance compound present in FM I. OBJECTIVES: To study contact allergy to citral, geranial, and neral, and concomitant reactivity to oxidized geraniol and fragrance markers of the baseline series. METHODS: A total of 1476 dermatitis patients with suspected allergic contact dermatitis were patch tested using geranial, neral, and citral, all 3.5% petrolatum (pet.) as well as geraniol 6.0% and oxidized geraniol 11% pet. in addition to the Swedish baseline series. RESULTS: Frequencies of positive reactions to citral, geranial, and neral were 2.9%, 3.4% and 1.9%, respectively. Together, citral and geranial gave 4.2% positive patch test reactions in consecutive dermatitis patients. In patients with positive reactions to citral or its components, 25% to 34% reacted to FM II and 61% reacted to oxidized geraniol. CONCLUSIONS: Patch testing with citral, its components, or oxidized geraniol detects contact allergic reactions not detected using the baseline series. Patch testing with pure geraniol was shown to be of little value. Geranial and neral, although closely chemically related, are concluded to be separate haptens.

Contact allergy to oxidized geraniol among Swedish dermatitis patients-A multicentre study by the Swedish Contact Dermatitis Research Group.

BACKGROUND: Geraniol is a widely used fragrance terpene, and is included in fragrance mix I. Geraniol is prone to autoxidation, forming the skin sensitizers geranial, neral, and geraniol-7-hydroperoxide. Oxidized geraniol has previously been patch tested in 1 clinic, giving 1% to 4.6% positive reactions in consecutive patients when tested at 2% to 11%. AIM: To compare test reactions to pure and oxidized geraniol, to compare 2 different test concentrations of oxidized geraniol and to investigate the pattern of concomitant reactions to fragrance markers of the baseline series in a multicentre setting. METHODS: One thousand four hundred and seventy-six consecutive patients referred for patch testing were patch tested with geraniol 6% pet. and oxidized geraniol 6% and 11% pet. RESULTS: Pure geraniol 6% pet., oxidized geraniol 6% pet. and oxidized geraniol 11% pet. gave 1%, 3% and 8% positive patch test reactions and 0.7%, 3% and 5% doubtful reactions, respectively. Approximately 50% of the patients with doubtful reactions to oxidized geraniol 6% pet. had positive reactions to oxidized geraniol 11% pet. CONCLUSIONS: Oxidized geraniol 11% pet. provides better detection than oxidized geraniol 6% pet. As most patients reacted only to oxidized geraniol, it is important to explore further whether oxidized geraniol should be included in a baseline patch test series.

Oxidized limonene and oxidized linalool - concomitant contact allergy to common fragrance terpenes.

BACKGROUND: Limonene and linalool are common fragrance terpenes. Both oxidized R-limonene and oxidized linalool have recently been patch tested in an international setting, showing contact allergy in 5.2% and 6.9% of dermatitis patients, respectively. OBJECTIVE: To investigate concomitant reactions between oxidized R-limonene and oxidized linalool in consecutive dermatitis patients. METHODS: Oxidized R-limonene 3.0% (containing limonene hydroperoxides 0.33%) and oxidized linalool 6% (linalool hydroperoxides 1%) in petrolatum were tested in 2900 consecutive dermatitis patients in Australia, Denmark, Singapore, Spain, Sweden, and the United Kingdom. RESULTS: A total of 281 patients reacted to either oxidized R-limonene or oxidized linalool. Of these, 25% had concomitant reactions to both compounds, whereas 29% reacted only to oxidized R-limonene and 46% only to oxidized linalool. Of the 152 patients reacting to oxidized R-limonene, 46% reacted to oxidized linalool, whereas 35% of the 200 patients reacting to oxidized linalool also reacted to oxidized R-limonene. CONCLUSIONS: The majority of the patients (75%) reacted to only one of the oxidation mixtures, thus supporting the specificity of the reactions. The concomitant reactions to the two fragrance allergens suggest multiple sensitizations, which most likely reflect the exposure to the different fragrance materials in various types of consumer products. This is in accordance with what is generally seen for patch test reactions to fragrance materials.

Air-oxidized linalyl acetate - an emerging fragrance allergen?

BACKGROUND: Linalyl acetate is a fragrance chemical that is prone to autoxidation. Exposure to linalyl acetate occurs through cosmetic products and essential oils, but is difficult to assess, as linalyl acetate is not labelled in the EU. OBJECTIVE: To investigate the frequencies of contact allergy to oxidized linalyl acetate among dermatitis patients, and to investigate the autoxidation of linalyl acetate in terms of hydroperoxide formation and sensitization potency. PATIENTS AND METHODS: Hydroperoxide formation in air-exposed linalyl acetate was determined with high-performance liquid chromatography. The sensitization potencies of hydroperoxides were determined with the local lymph node assay. One thousand seven hundred and seventeen patients were patch tested with oxidized linalyl acetate at 6.0% in petrolatum. RESULTS: Of the patients, 2.2% showed positive reactions to oxidized linalyl acetate. Forty-three per cent of the positive patients also had positive patch test reactions to other fragrance markers. Linalyl acetate hydroperoxides were detected early in the autoxidation process, and accumulated to a concentration of 37% after 42 weeks of air exposure. The linalyl acetate hydroperoxides were classified as moderate sensitizers. CONCLUSIONS: The frequency of positive reactions to oxidized linalyl acetate is comparable to that of previously studied oxidized fragrance terpenes. Oxidized linalyl acetate could thus be a common fragrance contact allergen.

Patch testing with a textile dye mix in two concentrations - a multicentre study by the Swedish contact dermatitis research group.

UNLABELLED: Disperse dyes, which are used for colouring synthetic textile fibres, are well-known contact sensitisers. To investigate the outcome of patch-testing with a textile dye mix (TDM) at 7 dermatology clinics in Sweden, a TDM tested at 2 concentrations was included into the baseline series during one year. The mix consisted of Disperse (D) Blue 35, D Yellow 3, D Orange 1 and 3, D Red 1 and 17, all 1.0%, and D Blue 106 and D Blue 124, each 0.3% in the mix 6.6% and 1.0% each in the mix 8.0%. In 2,122 tested patients, contact allergy to the TDM at the concentration 8.0% was found in 2.8% and to the TDM at 6.6% in 2.5% of the patients. The contact allergy to the TDM could explain or contribute to the dermatitis in about 35% of the patients. CONCLUSION: contact allergy to the TDM is common and inclusion into the Swedish baseline series should be considered.

Swedish Experiences From Patch Testing Methylisothiazolinone Separately.

The preservative methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) is a well-known sensitiser and present in the Swedish baseline series since the 1980s. The proportions of MCI/MI are 3:1. MI alone has been used as a preservative since less than 10 years. This study was conducted on behalf of the Swedish Contact Dermatitis Research Group to evaluate inclusion of MI in the Swedish baseline series since the preparation of MCI/MI might fail to detect contact-allergic reactions to MI alone. Patients with suspected allergic contact dermatitis at 5 Swedish dermatology departments were consecutively patch tested with MI 2,000 ppm aq and MCI/MI 200 ppm aq. The number of cases with exclusive contact allergy to MI varied between 0.8-4.2%. In total, 1.9% reacted exclusively to MI and not to MCI/MI. Due to the considerable frequency of contact allergy to MI not traced by MCI/MI, MI 2,000 ppm aq is included in the Swedish baseline series from January 2014. This corresponds to a dose of 60 µg/cm2.

Cross-reactivity between citral and geraniol - can it be attributed to oxidized geraniol?

BACKGROUND: The fragrance compound geraniol is susceptible to autoxidation when in contact with air, and to cutaneous metabolism. In both processes, the isomeric aldehydes geranial and neral are formed. Citral consists of geranial and neral. Among patients with positive reactions to citral, we have previously detected concomitant reactions to geraniol in 85% of cases and to oxidized geraniol in 73% of cases. OBJECTIVE: To study the pattern of concomitant reactions to geraniol and citral and its isomers geranial and neral, and to determine whether these isomers are important sensitizers in contact allergy to geraniol and oxidized geraniol. PATIENTS AND METHODS: The irritancy of geranial and citral was studied. Six hundred and fifty-five patients were patch tested with geranial, neral and citral at 3.5% pet., pure geraniol at 6.0% and 11.0% pet., and oxidized geraniol at 6.0% pet. RESULTS: Twenty-six per cent of citral-positive patients reacted to oxidized geraniol, and 10.5% reacted to pure geraniol. Citral and/or its isomers gave positive reactions in 25% of the patients who reacted to pure geraniol. CONCLUSIONS: There is little cross-reactivity between pure geraniol and citral; however, concomitant reactions to citral and oxidized geraniol were common, owing to geranial. Geranial was also the main sensitizer in the mixture citral.

Positive patch test reactions to oxidized limonene: exposure and relevance.

BACKGROUND: R-Limonene is a common fragrance terpene found in domestic and industrial products. R-Limonene autoxidizes on air exposure, and the oxidation products can cause contact allergy. In a recent multicentre study, 5.2% (range 2.3-12.1%) of 2900 patients showed a positive patch test reaction to oxidized R-limonene. OBJECTIVE: To study the exposure to limonene among consecutive dermatitis patients reacting to oxidized R-limonene in an international setting, and to assess the relevance of the exposure for the patients' dermatitis. METHODS: Oxidized R-limonene 3.0% (containing limonene hydroperoxides at 0.33%) in petrolatum was tested in 2900 consecutive dermatitis patients in Australia, Denmark, the United Kingdom, Singapore, Spain, and Sweden. A questionnaire assessing exposure to limonene-containing products was completed. RESULTS: Overall, exposure to products containing limonene was found and assessed as being probably relevant for the patients' dermatitis in 36% of the limonene-allergic patients. In Barcelona and Copenhagen, > 70% of the patients were judged to have had an exposure to limonene assessed as relevant. CONCLUSIONS: Oxidized R-limonene is a common fragrance allergen, and limonene was frequently found in the labelling on the patients' products, and assessed as relevant for the patients' dermatitis. A large number of domestic and occupational sources for contact with R-limonene were identified.

Air-oxidized linalool elicits eczema in allergic patients - a repeated open application test study.

BACKGROUND: Linalool is a commonly used fragrance terpene that forms potent sensitizers upon oxidation. In a recent multicentre study, we found that 7% of 2900 patients showed positive patch test reactions to oxidized linalool at 6.0%. No elicitation studies have been performed. OBJECTIVE: To identify threshold concentrations for elicitation of allergic contact dermatitis caused by oxidized linalool in allergic individuals with repeated exposures. METHODS: Repeated open application tests were performed in 6 participants previously diagnosed with contact allergy to oxidized linalool. Creams containing 3.0%, 1.0% and 0.30% oxidized linalool (corresponding to 0.56%, 0.19% and 0.056% linalool hydroperoxides, respectively) and 'fine fragrance' containing 1.0%, 0.30% and 0.10% oxidized linalool (corresponding to 0.19%, 0.056% and 0.019% linalool hydroperoxides, respectively) were used twice daily for up to 3 weeks. Patch testing with a dilution series of oxidized linalool was performed. RESULTS: Five of 6 participants reacted to the cream containing 3% oxidized linalool. With 1% oxidized linalool, a reaction was seen in 3 (cream) and 4 (fine fragrance) participants, respectively. With 0.3% oxidized linalool, 2 (cream) and 1 (fine fragrance) participants reacted. CONCLUSION: Repeated exposure to low concentrations of oxidized linalool can elicit allergic contact dermatitis in previously sensitized individuals.

Patch testing with formaldehyde 2.0% in parallel with 1.0% by the Swedish contact dermatitis research group.

In a multicentre study consecutively patch-tested dermatitis patients were tested simultaneously with 1.0% and 2.0% (w/v) formaldehyde in aqua applied with a micropipette (15 µl) to the filter paper disc in Finn Chambers (0.30 mg/cm(2) and 0.60 mg/cm(2), respectively). A total of 2,122 dermatitis patients were patch-tested. In all, 77 (3.6%) patients reacted positively to formaldehyde; 37 reacted only to 2.0%, 35 reacted to both concentrations and 5 patients reacted only to 1.0%. Significantly more patients were thus diagnosed with contact allergy to formaldehyde with 2.0% compared to 1.0% (p < 0.001) without causing more irritant reactions. The detected number of isolated allergic reactions to the 2 formaldehyde-releasers in the Swedish baseline series and not to formaldehyde itself raises the question whether quaternium-15 1.0% and diazolidinyl urea 2.0% should be present in the Swedish baseline series.

An international multicentre study on the allergenic activity of air-oxidized R-limonene.

BACKGROUND: Limonene is a common fragrance terpene that, in its pure form, is not allergenic or is a very weak allergen. However, limonene autoxidizes on air exposure, and the oxidation products can cause contact allergy. Oxidized R-limonene has previously been patch tested in multicentre studies, giving 2-3% positive patch test reactions in consecutive patients. OBJECTIVES: To investigate whether oxidized R-limonene 3.0% in petrolatum, with a stable concentration of the main haptens, limonene hydroperoxides (Lim-OOHs), could be a useful tool for the detection of contact allergy in an international setting. METHODS: Oxidized R-limonene 3.0% (Lim-OOHs 0.33%) pet. was tested in 2900 consecutive dermatitis patients in Denmark, the United Kingdom, Singapore, Spain, Sweden, and Australia. RESULTS: Overall, 5.2% (range 2.3-12.1%) of the patients showed a positive patch test reaction to oxidized R-limonene. Doubtful reactions were found in 7.0% of the patients (range 0-24%). Few irritant reactions were seen. CONCLUSIONS: Oxidized R-limonene at 3.0% pet. with a specified content of Lim-OOHs 0.33% is a standardized and useful tool for the detection of contact allergy in dermatitis patients. Many patients showing positive patch test reactions to oxidized R-limonene would not be informed of their fragrance allergy if this specific test had not been performed.

Air-oxidized linalool: a frequent cause of fragrance contact allergy.

BACKGROUND: Linalool is a common fragrance terpene that, in pure form, is not allergenic or is a very weak allergen. However, linalool autoxidizes on air exposure, and the oxidation products can cause contact allergy. In a Swedish study, oxidized linalool 6.0% in petrolatum (pet.) gave 5% positive patch test reactions in 2500 dermatitis patients. OBJECTIVES: To investigate whether oxidized linalool 6%, with a stable concentration of the main haptens, the linalool hydroperoxides (Lin-OOHs) in pet., could be a useful tool for the detection of contact allergy in an international setting. Methods. Oxidized linalool 6.0% (Lin-OOHs 1%) pet. was tested in 2900 consecutive dermatitis patients in Denmark, the United Kingdom, Singapore, Spain, Sweden, and Australia. RESULTS: Overall, 6.9% (range 3-13%) of the patients showed positive patch test reactions to oxidized linalool. Doubtful reactions were found in 9.2% of the patients (range 0-36%). Few irritant reactions were seen. CONCLUSIONS: In an international setting, oxidized linalool has been shown to be a common allergen. Oxidized linalool 6.0% (Lin-OOHs 1%) pet. is a useful, standardized and stable tool for the detection of contact allergy in dermatitis patients. Many patients showing positive patch test reactions to oxidized linalool would not have been informed of their fragrance allergy if this specific test had not been performed.

Air oxidation increases skin irritation from fragrance terpenes.

BACKGROUND: Linalool and limonene are common fragrance terpenes that autoxidize on air exposure. The pure compounds are not allergenic but their oxidation products can cause contact allergy. Little has been investigated regarding the irritancy of oxidized terpenes. AIM: The aim of this study was to investigate the irritating effect of pure and oxidized R-limonene and linalool in concentration series and to study the MNIC (Maximum Non Irritant Concentration) of autoxidized linalool and limonene. PATIENTS/METHODS: Patch testing was performed in dermatitis patients and controls with sequentially diluted concentrations of oxidized and non-oxidized linalool, and oxidized and non-oxidized R-limonene. Readings were made with visual assessment and using laser Doppler imaging. RESULTS: The non-oxidized terpenes were non-irritating in all tested concentrations. Both linalool and especially R-limonene were more irritating after oxidation compared with the pure compounds. No difference in response was seen between dermatitis patients and controls. CONCLUSION: Autoxidation of the fragrance terpenes linalool and R-limonene increases irritation. Oxidized linalool is less irritating than oxidized R-limonene. In this study, we found no advantages in using laser Doppler technique compared with visual assessment.

Lavender oil lacks natural protection against autoxidation, forming strong contact allergens on air exposure.

BACKGROUND: Lavender oil is an essential oil frequently used as a fragrance ingredient and in traditional herbal medicine. We have previously studied the effect of air oxidation on the skin sensitizing potency of the monoterpenes linalyl acetate, linalool and beta-caryophyllene, the main constituents of lavender oil. OBJECTIVE: The aim of this study was to investigate if the autoxidation observed for the single synthetic terpenes, resulting in strong contact allergens, will take place also in lavender oil. METHODS: Lavender oil was exposed to air and the autoxidation was followed by chemical analysis. The sensitizing potency before and after air exposure was investigated in mice using the local lymph node assay. Patients with patch test reactions to oxidized linalool were tested to investigate if air-exposed lavender oil could elicit dermatitis in these individuals. RESULTS: The terpenes oxidized in air-exposed lavender oil at the same rates as the pure compounds exposed to air, and the same oxidation products were identified. The sensitizing potency of lavender oil increased accordingly on air exposure. Patch testing showed positive reactions to air-exposed lavender oil and also to oxidized linalyl acetate in patients with contact allergy to oxidized linalool. CONCLUSION: This study shows that lavender oil lacks natural protection against autoxidation, and that air-exposed lavender oil can be an important source of exposure to allergenic hydroperoxides.