Allergic Contact Dermatitis to Plant Extracts in Cosmetics

Transcription

Allergic Contact Dermatitis
to Plant Extracts in Cosmetics
Alexander R. Jack, MD, Patricia L. Norris, MD, and Frances J. Storrs, MD
Topically applied cosmetics and medicaments containing botanical extracts are commonly
used. Despite popular beliefs of their benignancy, some botanicals have been implicated in
causing allergic contact dermatitis in susceptible patients. The offending allergen may be
the botanical extract itself or another ingredient such as a fragrance, preservative, dye, or
sunscreen found in the product. Specific botanicals implicated in causing cosmetic contact
dermatitis include Compositae family plants, tea tree oil, peppermint, lavender, lichens,
henna, and others.
Semin Cutan Med Surg 32:140-146 © 2013 Frontline Medical Communications
KEYWORDS allergic contact dermatitis, cosmetics, botanicals, plants
D
uring the past several decades, there has been increasing
use of topical cosmetics and medicaments containing
botanical extracts.1,2 In a recent survey of 400 dermatology
and allergy patients, 60.25% of respondents reported the use
of ‘natural’ topical products.3 The popular appeal of botanicals may be attributed to the conventional wisdom that plant
products have beneficial effects, such as treating common
illnesses, while having little risk of adverse effects.4
Despite popular beliefs of their benignancy, cosmetic
products containing botanicals have been implicated in causing adverse cutaneous reactions. In the aforementioned study
of 400 patients, 6.22% of users reported unpleasant skin
reactions to one or more of their botanical products.3 Previous reviews have shown that many popular botanical extracts
have been reported to cause allergic contact dermatitis.4,5
The majority of adverse reactions to cosmetic products are
irritant, which can manifest with unpleasant sensations (eg,
burning, stinging) and/or nonimmunologically mediated
skin inflammation in areas where the product is applied.6,7
Allergic contact dermatitis to cosmetics typically presents as a
low-grade chronic eczematous dermatitis rather than an
acute vesicular eruption as most cosmetic allergens are lowgrade.8 Affected areas are typically located on the face and
localized to areas where the cosmetic is applied; however,
connubial dermatitis (transfer of allergen from skin contact
Department of Dermatology, Oregon Health & Science University, Portland, Oregon.
Disclosures: The authors have completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and none were reported.
Correspondence: Alexander R. Jack, MD, Oregon Health & Science University, 3303 SW Bond Ave., CH16D, Portland, OR 97239. E-mail:
[email protected]
140
with another person) and dermatitis from transfer of allergens from fomites (eg, pillowcases, towels) has been reported.7
It is important to note that allergic contact dermatitis to
cosmetics is relatively infrequent given their widespread use,
but still occurs in a significant number of patients. Incorporating data from a number of studies, Biebl et al reported
pooled prevalence of allergic contact dermatitis to cosmetics
at 9.8% in patients undergoing patch testing and 0.4% in the
general population.7 Cosmetic dermatitis patients may have
contact allergy to a botanical extract found in their product.9
However, one must consider a reaction to other components
of the cosmetic such as fragrances, preservatives, and sunscreens.9
Some studies have estimated the prevalence of botanical
extract allergy in patients with contact dermatitis to cosmetics. In a prospective study of 29 patients with cosmetic dermatitis, 79% of patients demonstrated positive patch-test reactions to Fragrance Mix I and 34% to Balsam of Peru.10
Patients in this study were tested with an extended series of
plant extract allergens; the most prevalent reactions were
39% to one or more Compositae plants and 24% to tea tree
oil.10 Simpson et al showed that in 21 patients at ‘high risk’
for botanical allergy (those using botanical products whose
contact allergen was not explained by patch testing to standard allergens), 48% had a relevant reaction to a botanical
extract.11 Of these relevant reactions, the most prevalent were
Compositae plants, tea tree oil, lichens, and geranium.11 Of all
patients with positive patch test reactions, the most common
allergens were fragrance mix (33%), Balsam of Peru (30%),
Compositae mix (20%), and sesquiterpene lactone mix
(6.7%).11 These results suggest that fragrance mix and Bal-
1085-5629/13/$-see front matter © 2013 Frontline Medical Communications
DOI: 10.12788/j.sder.0019
Allergic contact dermatitis in cosmetics
sam of Peru may be useful screening allergens for botanical
extract allergy.
In the upcoming sections, specific plant allergens implicated in cosmetic contact dermatitis will be reviewed.
Compositae Family
The Compositae family of plants is one of the largest in the
world and includes common weeds (eg, ragweed), ornamental plants (eg, chrysanthemum), vegetables (eg, artichoke),
and herbs (eg, chamomile). They are mostly herbaceous
plants with characteristic flowers generally consisting of 1-2
layers of numerous small flowers (florets) radially clustered
to form a flower head (capitulum) subtended by an involucre
(whorl of bracts) (Figure 1).12 The major sensitizers are sesquiterpene lactones (SQLs), which are found in stems, leaves,
and flowers.12 They are a diverse group of compounds containing a sesquiterpene (C15H24) and a lactone ring (cyclic
ester).12
Many of the most widely used medicinal plants contained
in cosmetics and topical medicaments are from the Compositae family. Those reported to have caused allergic contact
dermatitis are listed in Table 1.5,13
Compositae dermatitis typically presents in an airborne distribution and affects those with exposure to plants including
outdoor workers, farmers, loggers, gardeners, and florists.12,13 Of all cases of Compositae dermatitis, topical agents
may be a relatively uncommon culprit. In a review of 118
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Table 1 Compositae Plants Implicated in Causing Allergic
Contact Dermatitis
Common Name
Scientific Name
Arinca
Marigold
German chamomile
Roman chamomile
Feverfew
Dandelion
Yarrow
Purple coneflower
Elecampane
Sticky elecampane
Mugwort
Great burdock
Dog fennel
Costus
French marigold
Arnica montana
Calendula officinalis
Chamomilla recutita
Chamaemelum nobile
Tanacetum parthenium
Taraxacum officinale
Achillae millefolium
Echinacea purpurea
Inula helenium
Inula viscose
Artemisia vulgaris
Arctium lappa
Anthemis cotula
Saussurea lappa
Tagetes patula
patients with positive patch-test reactions to Compositae mix,
Hausen reported only 10 patients (8.5%) whose dermatitis
was explained by contact with a topical medicament or cosmetic.14 Note that this study was published in 1996 and
dermatitis to botanical extracts in cosmetics may be more
common at the present time as usage of these products has
increased. More recent studies have demonstrated that a large
proportion of patients with Compositae allergy may be sensitized through the use of topical agents. Paulsen et al reported
that 8 of 12 patients sensitive to chamomile and 5 of 6 patients sensitive to arnica had positive patch-test reactions to
cosmetics and herbal remedies containing these plant extracts.15 In another study involving 443 patch-test patients, 5
(1.13%) reacted to arnica and 9 (2.03%) reacted to Calendula
(marigold).16 Of these, 3 of 5 arnica-sensitive patients and 6
of 9 marigold-sensitive patients recalled using a topical product containing the respective botanical extracts.16 Taken together, these findings suggest that patients sensitized to a
Compositae plant through any means (either through outdoor
exposure or through usage of a topical product) should avoid
products containing Compositae extracts.14-16
The North American Contact Dermatitis Group (NACDG)
screening panel contains 2 standard allergens relevant to
Compositae dermatitis: sesquiterpene lactone mix (SL mix)
and Compositae mix (CM). SL mix is composed of 3 purified
sesquiterpene lactones: costunolide, dehydrocostuslactone,
and alantolactone.17 CM is comprised of extracts from 5 Compositae plants:14

Figure 1 Yarrow, a member of the Compositae family. Note the herbaceous foliage and numerous flowers consisting of small, radially
clustered florets.
Arnica montana,
Matriacaria recutica,
Tancetum parthenium,
Tancetum vulgare, and
Achiellea millefolium.
The utility of SL mix relative to CM has been questioned as
some reports11,18-20 have demonstrated a low prevalence of
positive patch-test reactions to SL mix in Compositae-sensitive patients; however, another study showed that SL mix and
A.R. Jack, P.L. Norris, and F.J. Storrs
142
Table 2 Plant Allergens Included in the Supplemental Plant Series (Chemotechnique Diagnostics, Vellinge, Sweden)
Allergen
Relevance
Anthemis nobilis extract
Diallyl disulfide
Arnica montana extract
Taraxacum officinale
Achillea millefolium extract
Propolis
Chrysanthemum cinerariaefolium
Sesquiterpene lactone mix
␣-Methylene-␥-butyrolactone
Tanacetum vulgare extract
Alantolactone
Lichen acid mix
Parthenolide
Chamomilla recutita extract
Roman chamomile (Compositae family)
Irritant found in Allium plants (e.g. garlic)
Arnica (Compositae family)
Dandelion (Compositae family)
Yarrow (Compositae family)
Resinous mixture from honeybee
Pyrethrum (Compositae family), used in production of insecticide
Screen for Compositae allergy
Tansy (Compositae family)
Screen for lichen allergy
Feverfew (Compositae family)
German chamomile (Compositae family)
CM produce similar results.21 Limitations of CM include lack
of both a standardized manufacturing protocol and detailed
specification of constituent plants, which may result in variable concentrations of sesquiterpene lactones in different
batches.22 Given the potential for both SL mix and CM to
miss Compositae allergy, it is reasonable to patch-test patients
with suspected allergic contact dermatitis to Compositae-containing cosmetics to their own products in addition to these
standardized mixes. Additionally, a supplemental plant series that contains a number of specific Compositae plant extracts is available (Chemotechnique Diagnostics, Vellinge,
Sweden) (Table 2).
Tea Tree Oil
Tea tree oil (TTO) is an essential oil extracted via steam distillation from the leaves of the tree Melaleuca alternifolia,
which is a member of the Myrtaceae family and indigenous to
northeastern Australia. Well-known for its purported antimicrobial effects, TTO is found in many products including
shampoos, massage oils, aromatherapy candles, compresses,
inhalers, mouthwashes, laundry detergents, fabric softeners,
and moisturizers.23 TTO contains many distinct chemical
compounds. Both its antimicrobial and sensitizing properties
are likely attributable to the terpene and hydrocarbon components, notably terpinen-4-ol.23 Degradation products created by photo-oxidation of TTO are more potent sensitizers
than fresh TTO, thus using an old product may result in a
higher potential for sensitization.24
A retrospective study of 2,520 patients undergoing patch
testing in Australia demonstrated a 1.8% prevalence of positive patch tests to TTO; 41% of positive reactions were
deemed relevant.25 This prevalence rate was higher than that
reported by other groups in Europe and North America.24,26
The North American Contact Dermatitis Group has reported
a 1.4% prevalence of positive patch-test reactions in 20052006, a significant increase from the 0.9% prevalence seen in
1994-2004.27 Allergic contact dermatitis due to TTO has
been reported when it has been used as treatment for dog
scratches, tinea pedis, insect bites, hand dermatitis, folliculitis, acne, bronchitis, warts, vulvovaginitis, and skin abrasions
(Figure 2).28 Additionally, an erythema multiform-like id reaction secondary to allergic contact dermatitis to TTO has
been reported.29
Figure 2 (A) Eczematous plaques on the extensor knee of a patient using a topical preparation containing tea tree oil for
joint pain. (B) Note the positive patch test reaction to tea tree oil 5% in pet.
The NACDG screening panel contains TTO 5% in petrolatum. When the index of suspicion is high, patch testing
with both TTO 5% in petrolatum and with the patient’s own
products is recommended.30 Patch-test results should be interpreted carefully as TTO, particularly in high concentrations, is a known irritant.23
Peppermint Oil
Peppermint oil (PO) is extracted via steam distillation from
the above-ground portion of Mentha piperita, a perennial
herb native to the Mediterranean region but is now widely
cultivated. Mentha piperita is a member of the Labiatae family,
which includes other fragrant herbs such as lavender. PO is
well-known for its fresh odor, pungent taste, and cooling
effects when topically applied. It has been used as a fragrance,
flavoring agent, antipruritic, and analgesic.31 Products containing PO include lip balms, mouthwashes, breath fresheners, toothpastes, chewing gums, dental floss, teas, confections, and dissolving oral strips.31,32 The primary constituents
of PO are menthol and menthone; notable minor constituents include limonene, carvone, and pulegone, the last of
which is a known hepatotoxin.33,34
Tran et al published a recent case series of 4 patients with
allergic contact cheilitis that were deemed most likely secondary to peppermint oil in lip balm and other lip products.32 Allergic contact dermatitis to PO has been reported
with topical use on skin.35,36 Additionally, PO has been implicated in provoking disorders of the oral cavity including
stomatitis, burning mouth syndrome, recurrent oral ulcers,
and oral lichenoid reactions.37 There is a case report of systemic contact dermatitis presenting as vulvar dermatitis
thought to be secondary to oral ingestion of peppermint
tea.38
Mentha piperita oil 2% in petrolatum was a new addition to
the NACDG screening panel in the 2009-2010 reporting period.39 During this period, the NACDG has reported a 0.6%
prevalence of positive patch-test reactions to PO with 72%
being of definite, probable, or possible relevance.39 It should
be noted that PO in higher concentrations (over 5%) may be
an irritant.31,33
Lavender Oil
Lavender oil (LO) is an essential oil that is most commonly
derived from 1 of 4 species of lavender, Lavandula augustifolia. LO has been used for its purported sedative, antidepressive, and antimicrobial and fragrant properties.40 Products
containing LO include soaps, cleansers, moisturizers, massage oils, and aromatherapy oils.41 The main components of
LO include linalool, linalyl acetate, and camphor.40
Allergic contact dermatitis to LO has been reported in
armoatherapists; massage therapists; reflexologists; and
physiotherapists through occupational exposure to massage
oil and aromatherapy oil.42,43 The prevalence of allergic contact dermatitis to LO may be particularly high in Japan where
it has gained widespread household use. Sugiura et al reported that 3.8% of 1,483 patients with suspected cosmetic
143
contact dermatitis had positive patch-test reactions to LO.44
The percentage of positive patch-test reactions increased
from 1.1% in 1990 to 13.8% in 1998, which correlated with
increased household use of LO during the study period.44 A
potential limitation of this study is that the authors used a
concentration of 20% LO in petrolatum to patch test, which
may have resulted in a high proportion of irritant reactions.
Like PO, LO is a recent addition to the NACDG screening
panel and is patch tested with Lavandula augustifolia oil 2% in
petrolatum.39 During the 2009-2010 reporting period, the
NACDG reported a 0.2% prevalence of positive patch-test
reactions with 80% of reactions being of definite, probable,
or possible relevance.39
Lichens
Lichens are an extremely diverse group of plant-like, composite organisms that consist of a fungus living in symbiosis
with an alga or cyanobacterium. They have become popular
additions to cosmetics, particularly deodorants, moisturizers, and ‘healing’ creams, due to their purported antimicrobial properties.45 The principle allergens in lichens include
usnic acid, atranorin, and everinic acid, which are produced
by the fungal component.46
Sheu et al reported a case series of 4 patients with allergic
contact dermatitis to lichen extract in deodorants (Figure
3).46 Three of 4 patients presented with axillary dermatitis;
however, 1 patient presented with an ear dermatitis due to
connubial allergen transfer from the deodorant in her husband’s axilla.46
The NACDG screening panel does not contain a specific
allergen screen for lichen allergy. Lichen acid mix— consisting of 0.1% d-usinc acid, 0.1% atranorin, and 0.1% everinic
acid pet—is available (Chemotechnique Diagnostics, Vellinge, Sweden). It should be noted that Fragrance Mix I contains oak moss absolute, which is derived from the extract of
the lichen Evernia prunastri. However, there is no known
cross reactivity between lichen mix and oak moss absolute.
Henna
Henna is derived from the flowering plant Lawsonia inermis,
which grows in tropical and subtropical regions of Africa,
southern Asia, and northern Australia. Henna is a member of
the Lythraceae family. Reconstituted powder from dried
henna leaves have been used since medieval times as a dye for
coloring and tattooing the skin, hair, and nails. Para-phenylenediamine (PPD), a widely reported sensitizer, is often
added to henna dye to enhance coloring. The PPD additive
significantly increases the risk of allergic contact dermatitis to
products containing henna.47 Henna tattoos have been suggested as an important means of sensitization to PPD, which
may increase one’s risk for developing contact dermatitis to
conventional hair-dyeing products.48
Although the sensitizer in cosmetics containing henna is often
PPD or other additives, allergic contact dermatitis may be secondary to lawsone (2-hydroxy-1, 4-naphthoquinone) in henna
itself.49 A 3-year-old girl was reported to have severe bullous
144
Figure 3 (A) Eczematous plaques in the axillary vault of a patient using a ‘natural’ deodorant containing lichen extract.
(B) Note the positive patch test reactions to lichen acid mix 0.3% in pet, D-usnic acid 1% in pet, and the deodorant.
allergic contact dermatitis from pure henna without PPD.49 Another case of contact dermatitis to pure henna was reported in a
man using a henna solution topically for rheumatic pain.50 A
9-year-old boy was found to be sensitized to both PPD and
henna in an allergic contact reaction to a henna tattoo.51
The NACDG standard tray contains PPD and therefore will
suffice for screening of most cases of contact dermatitis to henna-containing products. In patients with suspected dermatitis to
henna products that are PPD patch test negative, it would be
reasonable to patch test with 10% henna in petrolatum.49
Other Plant Allergens
There are many plant extracts that have been reported to
cause allergic contact dermatitis through cosmetic use in one
or a limited number of reports. These include Aloe vera,52
Azadirachta indica oil (neem oil),53,54 Centella asiatica (centella),55,56 Curcuma longa (tumeric),57-59 Glycyrrhiza glabra
(licorice),60 Hamamelis virginiana (witch hazel),61 Olea europaea oil (olive oil),62 Ricinus communis oil (castor oil
plant),63-65 Rosa centifolia (cabbage rose),66 Rosmarinus officinalis (rosemary),67-69 Salvia officinalis (sage),70 Simmondsia
chinensis (jojoba),71,72 and Thymus vulgaris (thyme).67
Conclusions
Already commonly used, cosmetics and medicaments containing botanical extracts are likely to increase in popularity.
Allergic contact dermatitis to topically applied botanical
products is relatively infrequent given their widespread use.
However, the allergic reaction certainly does occur in a small
percentage of individuals. When there is a high suspicion for
botanical contact dermatitis, a careful history should be obtained including a review of ingredients in all of the patient’s
cosmetics and topical medicaments. Note potential offending
allergens include fragrances, preservatives, dyes, sunscreens,
and botanical extracts. Plant allergens commonly implicated
in causing cosmetic contact dermatitis are summarized in
Table 3.
When patch testing for suspected cosmetic dermatitis, one
should note that the fragrance mixes and Balsam of Peru are
useful screening allergens.11 Relevant allergens on the
NACDG standard tray specific to botanicals include Compositae mix, sesquiterpene lactone mix, tea tree oil, Mentha piperita oil, and Lavandula augustifolia oil. Patch tests for botanical extracts should be interpreted with caution as in the case
of fragrance mixes, which are known to have a high prevalence of positive reactions but low relevance due to irritancy.73 In addition to standard allergens, supplemental plant
allergen trays may be considered. Patch testing a “leave on”
cosmetic product may be done, but a high frequency of irritant reactions should be anticipated. Finally, performing a
repeated open-application test (ROAT) by rubbing the suspected product into the antecubital skin twice daily for 1
week may aid in judging relevance.74
Table 3 Plant Extracts in Cosmetics Commonly Implicated in Causing Allergic Contact Dermatitis
Plant Family
Sensitizing Component
Relevant Plant Species
Compositae
Myrtaceae
Labiatae
Sesquiterpene lactones
Terpenes, hydrocarbons
Menthol, menthone, limonene, carvone,
linalool, linayl acetate, camphor
Usnic acid, atranorin, everinic acid
Lawsone
See Table 1
Tea tree (Melaleuca)
Peppermint (Mentha)
Lavender (Lavandula)
Many species (not a true plant)
Henna (Lawsonia)
Lichens
Lythracae
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