Myroxylon pereirae (balsam of Peru): Still worth testing?

BACKGROUND: Because Myroxylon pereirae (MP), or balsam of Peru, is nowadays almost not used "as such," and fragrance mix 1 (FM1) apparently is more sensitive in detecting fragrance allergy, the usefulness of testing MP in baseline series was recently questioned. OBJECTIVES: Identification of the number of clinically relevant patch test reactions to MP not detected by FM1. METHODS: Retrospective analysis of 12 030 patients patch tested with MP and FM1 for contact dermatitis between January 2018 and December 2019 in 13 Italian dermatology clinics. RESULTS: Four hundred thirty-nine patients (3.6%) had a positive patch test reaction to MP; 437 (3.6%) had a positive patch test reaction to FM1. Positive reactions to both MP and FM1 were observed in 119 subjects (1.0%), 310 (2.6%) reacted to MP only, 304 (2.5%) to FM1 only, 5 to MP and sorbitan sesquioleate (SSO), 9 to FM1 and SSO, and 5 to MP, FM1, and SSO. Single sensitizations were clinically relevant in 75.2% of cases for MP (62.9% current, 12.3% past) and 76.3% for FM1 (70.1% current, 6.2% past). CONCLUSIONS: Based on our results, MP appears to be still worth testing along with FM1 in baseline series, because it allows detection of a remarkable number of fragrance allergies, often relevant, which would be otherwise missed.

Patch test results with the European baseline series and additions thereof in the ESSCA network, 2015-2018.

BACKGROUND: Clinical surveillance of the prevalence of contact allergy in consecutively patch tested patients is a proven instrument to continually assess the importance of contact allergens (haptens) assembled in a baseline series. OBJECTIVES: To present current results from the European Surveillance System on Contact Allergies, including 13 countries represented by 1 to 11 departments. METHODS: Anonymized or pseudonymized patch test and clinical data from various data capture systems used locally or nationally as transferred to the Erlangen data centre were pooled and descriptively analysed after quality control. RESULTS: In the 4 years (2015-2018), data from 51 914 patients patch tested with the European baseline series (EBS) of contact allergens were analysed. Contact allergy to nickel was most frequent (17.6% positive), followed by contact allergy to fragrance mix I (6.9%), methylisothiazolinone (MI; 6.2%), and Myroxylon pereirae resin (balsam of Peru; 5.8%). CONCLUSIONS: While the prevalence of MI contact allergy decreased substantially following regulatory intervention, the persistently high levels of allergy to metals, fragrances, other preservatives, and rubber chemicals point to problems needing further research and, potentially, preventive efforts. Results with national additions to the baseline series provide important information on substances possibly to be considered for inclusion in the EBS.

Allergic Contact Dermatitis to Fragrances.

Allergic contact dermatitis to fragrance is common. The prevalence of fragrance allergy in the general population is between 0.7% and 2.6%. In patch-test populations, the positive reaction rate to fragrances ranges from 5% to 11%. The most common fragrance screeners in most baseline series include fragrance mix 1, fragrance mix 2, and Balsam of Peru. The addition of hydroxyisohexyl 3-cyclohexene carboxaldehyde, hydroperoxides of limonene, and hydroperoxides of linalool to screening series can further aid in the diagnosis of fragrance allergy. In the proper clinical setting, supplemental patch testing with an additional fragrance or essential oil series should be considered.

Patch Testing Results From the Massachusetts General Hospital Contact Dermatitis Clinic, 2007-2016.

BACKGROUND: Patch testing is the criterion standard for diagnosis of allergic contact dermatitis (ACD). OBJECTIVE: The aim of the study was to report the trends of patch testing results with the standard series at Massachusetts General Hospital from January 1, 2007, to December 31, 2016, compared with previous data from 1998 to 2006 and from 1990 to 2006 and those reported by the North American Contact Dermatitis Group. METHODS: Data were collected and analyzed from retrospective chart reviews, focusing on 50 allergens in our standard series. RESULTS: A total of 2373 patients were patch tested. One or more positive reactions were observed in 1428 patients (60.2%), and 1153 patients (48.6%) had a final primary diagnosis of ACD. Top 5 allergens were nickel (19.8%), fragrance mix I (14.6%), Myroxylon pereirae (balsam of Peru) (13.5%), neomycin (9.4%), and bacitracin (7.7%). Sensitization frequencies statistically increased over time for 3 allergens: nickel, neomycin, and propylene glycol, and decreased for 5 allergens: formaldehyde, paraben mix, thiuram mix, n-isopropyl-N-phenyl-4-phenylenediamine, and epoxy resin (P ≤ 0.001). CONCLUSIONS: Surveillance of ACD trends is essential to detect emerging sensitizers. Patch testing is an important diagnostic tool for detection of ACD to commonly encountered and potential allergens.

Alcohol-Related Dermatitis: A Review.

: Wine, beer, liquor, and spirits are widely consumed in many cultures across the globe, and for some individuals, ingestion, cutaneous contact, or other exposure can lead to dermatologic findings. However, there currently exist no comprehensive reviews on alcohol-related dermatitis. Herein, we will provide an overview of alcohol-related dermatitis and contact urticaria, including the epidemiology and clinical manifestations, potential allergens found in alcoholic beverages, testing approaches, and strategies for allergen avoidance.

Relative Prevalence of Contact Allergens in North America in 2018.

BACKGROUND: The American Contact Dermatitis Society Contact Allergen Management Program (CAMP) database was developed to provide patients with safe alternative products free of selected contact allergens. However, the CAMP database also records valuable information including the frequency of contact allergen searches for patients. OBJECTIVES: The aim of the study was to determine the relative prevalence of contact allergens in North America. METHODS: Data from the CAMP database were analyzed from January 1, 2018, to January 1, 2019. The number of searches performed for each specific allergen served as a measure of the relative prevalence for each contact allergen. Results were then stratified by age, sex, atopic history, and patch screening tray used. RESULTS: The 2018 CAMP data show that many of the prevalent allergens are not currently on any contact allergy screening series. These data strongly indicate that testing only to an 80-item screening series will not provide adequate care for many patients with contact allergy. The most prevalent contact allergens seen were fragrance mix, nickel, balsam of Peru, methylchloroisothiazolinone/methylisothiazolinone, and cobalt. Some important differences are seen when stratifying CAMP data by age, sex, atopic history, and patch screening tray used. LIMITATIONS: Possible sources of data error exist because of lack of uniformity of patch test practices. CONCLUSIONS: The CAMP database can be used to determine the relative prevalence of contact allergens, to help develop North American core screening patch test series, and to document the medical necessity of more comprehensive patch testing for patients with recalcitrant contact allergy.

Patch testing in Lao medical students.

BACKGROUND: Dermatological services in Laos, South East Asia are limited to the capital and patch testing is currently not available, so no data exists regarding the common cutaneous allergens in this population. OBJECTIVES: The aim of this study was to document positive patch tests in medical students without evidence of contact dermatitis in Laos. PATIENTS/MATERIALS/METHODS: One hundred and fifty medical students were patch tested using TRUE Test® panels 1 to 3 (35 allergens). Readings were taken at Days 2 and 4. RESULTS: Thirty-eight students (25.3%) had a positive reaction to at least one allergen, accounting for 52 reactions in total. The proportion of the students with positive patch test reading was significantly higher in the female [33/96 (34%)] than in the male [5/54 (9%)], p<0.001. The most common allergens were: nickel (10%), gold (6.6%), thiomersal (6.6%), cobalt dichloride (2%) and p-tert-Butylphenol formaldehyde resin (2%). Balsam of Peru (0.66%), black rubber mix (0.66%), Cl+Me-Isothiazolinone (0.66%), fragrance mix 1 (0.66%), quinolone mix (0.66%), methyldibromo glutaronitrile (0.66%), mercapto mix (0.66%), epoxy resin (0.66%), paraben mix (0.66%), thiuram (0.66%) and wool alcohols (0.66%) accounted for all of the other positive reactions. CONCLUSION: This study represents the first documented patch test results in Lao medical students and in the adult Lao population. The results of this study will inform any future research into contact allergy in Laos and give an insight into the background level of contact sensitivity in this population.

Chronic Actinic Dermatitis Revisited.

BACKGROUND: Chronic actinic dermatitis (CAD) is a persistent eczematous photodermatitis classically described in older, white men with contact allergy to plants. However, evidence from recent studies suggests that some demographics of CAD patients may be changing. OBJECTIVE: The aims of the study were to determine the frequency of CAD in patients presenting with photosensitive eruptions and to identify the allergens and photoallergens most closely associated with this condition. METHODS: We identified all patients with a diagnosis of CAD from 246 consecutive records of patients undergoing photopatch testing from July 1994 to June 2018 and summarized the demographics and test results in comparison with non-CAD patients. CONCLUSIONS: Nineteen (7.7%) of the 246 patients evaluated had CAD with a male-to-female ratio of 1:1.7 among CAD patients. Compared with non-CAD patients, photocontact allergy and/or contact allergy to sesquiterpene lactone mix and contact allergy to fragrances were significantly more common in CAD. Contact allergy to p-phenylenediamine was also common. The results of this study suggest that CAD presents in a broader demographic range, including both men and women of both light and dark skin types. Phototesting and photopatch testing should be considered when patients present with clinical findings consistent with CAD.

Systemic contact dermatitis related to alcoholic beverage consumption.

Systemic contact dermatitis is a rash secondary to systemic exposure to allergens after sensitization. Numerous agents are implicated including Balsam of Peru, a plant-derived compound often used for flavoring and fragrance. Alcoholic beverages can contain many possible allergens, including cinnamon, vanilla, citrus peels, and Balsam of Peru. Herein, we describe two patients presenting with recurrent, diffuse, erythematous, and pruritic cutaneous eruptions suspicious for contact dermatitis. Based on clinical history, exam, and formal and at-home patch testing results, we believe the most likely etiology was Balsam of Peru within the alcohol beverages leading to systemic contact dermatitis. Both patients markedly improved after avoidance of their alcoholic beverages. Overall, systemic contact dermatitis secondary to alcohol consumption is a rare phenomenon, whereas Balsam of Peru is a relatively common allergen. Suspicion must be high to identify possible allergens (including Balsam of Peru) exposure within alcoholic beverages such as artificial flavorings, aromas, and mixtures.

Myroxylon pereirae resin (balsam of Peru) - A critical review of the literature and assessment of the significance of positive patch test reactions and the usefulness of restrictive diets.

In this article, contact allergy to Myroxylon pereirae resin (MP) (balsam of Peru) is reviewed. The topics presented include the uses, the chemical composition, the frequency of sensitization, the relevance of positive reactions, the MP-containing products causing allergic contact dermatitis, co-reactivity with other fragrance and non-fragrance materials, the sensitizers, the usefulness of MP as a "marker" of fragrance allergy, and the effectiveness of, and indications for, "balsam-restrictive" diets. Sensitization to MP occurs in 4% to 8% of patients routinely tested for suspected contact dermatitis. There are few adequate data on relevance. Topical pharmaceuticals were formerly, but are not today, important sources of sensitization. Cosmetics and foods or drinks are hardly ever products responsible for sensitization to MP. Positive patch test reactions in the large majority probably result from previous sensitization to MP constituents because of their presence in fragrances and fragranced products, MP thereby acting as marker (or "indicator") of fragrance allergy. However, fragrance mix I is a more sensitive marker, and the added diagnostic value of testing with MP is unknown. The allergenic ingredients of MP include isoeugenol, eugenol and cinnamyl alcohol, but there are other-largely unknown-chemicals that are responsible for contact allergy. Suggestions are given for further research to address questions thus far unanswered and to improve patient care.

Lichen sclerosus et atrophicus and allergic contact dermatitis: A significant association.

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory skin disease of unknown etiology. It mainly affects the anogenital area, while the extragenital involvement is uncommon. It manifests as pale, ivory-colored lesions and partially atrophic skin. We report a case of a woman presenting to our department with LSA lesions at the level of the armpit. Furthermore, the patient was allergic to nickel sulfate and balsam of Peru. We assume the presence of an association between nickel allergy and onset of LSA.

Contact dermatitis and patch testing for the allergist.

OBJECTIVE: To review of contact dermatitis (CD) and its key allergens and provide updates and recommendations for the practicing allergist. DATA SOURCES: Through the use of various scientific search engines (eg, PubMed and MEDLINE), we reviewed literature on CD, patch tests (PTs), key allergens, occupational dermatitis, and treatment. STUDY SELECTIONS: Studies on CD, important allergens, and PTs were considered. RESULTS: Contact-induced dermatitis may be due to allergic CD, irritant CD, systemic CD, contact urticaria, and protein CD. Key allergens include metals (nickel, gold), topical medicaments (topical corticosteroids), and cosmetics and personal care products (fragrances and preservatives such as methyl- and methylchloro-isothiazolinone). Present relevance of a positive PT result is the combination of definite, probable, and possible relevance and should be correlated with the patient's history and physical examination. Treatment of allergic CD includes identification of relevant allergens, patient education, avoidance, and provision of alternative products the patient can use. CONCLUSION: CD is a common inflammatory skin disease and should be suspected in patients presenting with acute, subacute, or chronic dermatitis. The gold standard for diagnosing allergic CD is a PT. This article provides practical recommendations for the diagnosis and management of CD commonly seen by the allergist in their practice.

Photo-patch and patch tests in patients with dermatitis over the photo-exposed areas: A study of 101 cases from a tertiary care centre in India.

BACKGROUND: Many patients with dermatitis over photo-exposed body areas are positive to many contact allergens and have a pre-existing allergic contact dermatitis. METHODS: This study included patients who presented to a tertiary centre in India with dermatitis on photo-exposed body areas suspected of chronic actinic dermatitis. Their detailed histories were recorded and cutaneous and systemic examinations were performed. Patch testing was done in all the patients and photo-patch testing was carried out in 86 patients. RESULTS: Altogether 101 patients were included (69 males, 32 females). The most common presentation was lichenified hyperpigmented plaques on the photo-exposed sites. Photosensitivity was recorded in 64 (63%) patients and summer exacerbation in 52 (52%). Exposure to the Parthenium hysterophorus weed was recorded in 70 (69%) patients, 27 (26.7%) had a history of hair dye application and 20 (20%) had a history of atopy. Photo-patch test was positive in 11 (12.8%) patients and patch testing was positive in 71 (70%). Parthenium hysterophorus was the most common allergen implicated and was positive in three (4%) photo-patch and 52 (52%) patch tests. Other positive photo-patch test allergens were perfume mix, balsam of Peru, thiuram mix, Compositae mix and promethazine hydrochloride. Other common patch test allergens were parthenolide, colophony, fragrance mix and p-phenylenediamine (PPD) base. CONCLUSION: In the Indian population parthenium and perfume mix are the most common photoallergens in patients with dermatitis over photo-exposed areas, while parthenium, colophony, fragrance mix and PPD are the common positive allergens.

The current spectrum of contact sensitization in patients with chronic leg ulcers or stasis dermatitis - new data from the Information Network of Departments of Dermatology (IVDK).

BACKGROUND: Patients with lower leg dermatitis, chronic venous insufficiency or chronic leg ulcers have a high prevalence of contact sensitization. OBJECTIVES: To identify the current spectrum of contact allergens in these patients. PATIENTS AND METHODS: Data of the Information Network of Departments of Dermatology on 5264 patients with the above diagnoses from the years 2003 to 2014 (study group) were compared with data on 4881 corresponding patients from 1994 to 2003 (historical control group) and with a current control group without these diagnoses (n = 55 510). RESULTS: Allergic contact dermatitis was diagnosed less frequently in the study group than in the historical control group (25.9% versus 16.9%; p < 0.001), and contact sensitization to most allergens had declined. The allergen spectrum, however, was largely unchanged. Important allergens are Myroxylon pereirae (balsam of Peru) (14.8% positive reactions), fragrance mix I (11.4%), lanolin alcohol (7.8%), colophonium (6.6%), neomycin sulfate (5.0%), cetearyl alcohol (4.4%), oil of turpentine (3.1%), and paraben mix (2.6%). Patch testing with additional series showed sensitization to Amerchol L-101 (9.7%), tert-butyl hydroquinone (8.7%), framycetin sulfate (5.0%), and gentamicin sulfate (3.1%). CONCLUSIONS: Topical preparations for treating the above-mentioned conditions should not contain fragrances, Myroxylon pereirae, and colophonium. The special allergen spectrum has to be considered in patch testing.

Contact Alopecia: Improvement of Alopecia with Discontinuation of Fluocinolone Oil in Individuals Allergic to Balsam Fragrance.

Inflammatory scalp dermatoses can be associated with alopecia, which is nonscarring and reversible in its early stages. This association has been described in seborrheic dermatitis, psoriasis, and atopic dermatitis. We describe three girls with alopecia aggravated by contact allergy to balsam fragrances. All three had complete resolution with avoidance of balsam of Peru and other balsam derivatives (including discontinuation of fluocinolone oil, which contains balsam of pine).