Review Skin contact reactions to spices Skin contact reactwns to spices. Arev-few. L. Kanerva SUMMARY Spices and food ingredients relatively often trigger skin reactions of delayed or irnrnediate type. Both professionals, like chefs, catterers, as well as general population rnay be affected. Clove, Jarnaica pepper, garlic, paprika, vanilla and other spices are frequent causes of delayed type, while rnustard, coriander, careway, celery are the most cornrnon causes of the irnrnediate type skin allergy. The above rnentioned problerns are reviewed in details. 1. Introduction Skin is the most frequently affected organ of systemic IgE-mediated allergy to foods (1,2). However, contact with food may cause a localized "contact" reaction, either at the direct site of skin contact or upon contact with the lips and oral mucosa (oral allergy syndrome), or a more generalized skin reaction (systemic contact dermatitis). Skin contact reactions to foods and spices may occur in both the workplace and at home. It is well known that chefs, caterers, farmers, food handlers and preparers are occupationally exposed to foods ancl spices (F&S), but the list of jobs in which exposure to F&S allergens may occur is extensive. Spices are also used in cosmetics, perfumes, and medicaments, and allergic contact dermatitis may be causecl by these pro- clucts (1). Contact dermatitis to vanilla was recognizecl more than a centrny ago (1), ancl since then, numerous reports on skin reactions from F&S have been pu blishecl (1,2). Skin contacts with F&S may result in irritant contact dermatitis, allergic contact dermatitis (ACD), contact urticaria (CU), protein contact dermatitis (PCD), chemical photosensitivity (phototoxic and photoallergic reactions), ancl systemic ACD. These reactions can result from contact with a natura! food or spice, and food adclitives such as preservatives, flavorings, stabilizers, emulsifying agents, enzymes ancl antioxiclants, res- pectively. Often a combination of factors will contribute to skin contact reactions. An individual with hand dermatitis who works as a chef may have both irritant contact dermatitis from wet work and frequent hand washing, ancl ACD causecl by garlic or onion, as well as a Candida (3) or protein contact paronychia ( 4). The most common Acta Dermatoven APA Vol 10, 2001, No 1 ------------------------ ----------- 3 Skin contact reactions to spices clinical picture of contact dermatitis to F&S is hand ecze- ma. However, eczema and CU can also localize to the fingers anc.l palms with extension up the anns and invol- vement of the face and mouth (5) Protection and good skin care helps to prevent some ofthe symptoms. Atopic inclivic.luals are genetically prec.lisposecl to hancl derma- titis , ancl they have a greater incidence of irritant contact dermatitis ancl type I allergic reactions (5). Patch testing ancl prid: testings are necessa1y to ic.lentify or rule out the possibility of causative allergens. The present chapter is based on several recent book chapters or reviews on contact skin reactions causecl by foods anc.1 spices (1, 6-14). Much c.lata in contact dermatitis is based on case reports and many of the original references can be found in the above articles. 2. What are spices? Spices are the aromatic parts of plants such as the seecls , fruits, roots, bucls, flowers ancl barks. The boun- cra1y between spices, vegetables and aromatic plants is vague. For example, garlic, cayenne ancl paprika might be regarclecl as either vegetables or spices. The term herb is used of aromatic plants whose dried or fresh leaves or shoots are used. The flavoring constituents of spices are usually founcl in their ethereal oils. The main components of these are ohen known. Spices may cause c.lelayecl-type contact allergy, and/ or inm1ediate allergy (13-1 6). Spice oils and their constituents are also used in perfume1y. Spice oils contain substances, which may both irritate and cause type IV allergy (Table 1). Spices also contain proteins, which may cause immec.liate allergy. 3. Delayed allergy to spices Clove, Jamaica pepper (allspice), garlic, cinnamon, nutmeg, paprika, vanilla ancl ginger are the most fre- quent causes of ACD (13-21). Other causes of ACD are laurel (bay leat) (22), cardamom (23), t1.1rmeric (24) and mustard (25). There is a correlation between allergies to perfumes and spices due to their iclentical or related substances. Therefore, on patch testing with the stan- dard series, fragrance mix and balsam of Pern may detect contact allergy to e.g. clove, nutmeg, cinnamon, and cayenne pepper (21). Some pure allergens of spice oils are available from patch test allergen suppliers (Table 1). Patch tests can also be performed with ethereal oils of spices. In patch tests , clry powders of spices are put in Finn Chambers® on a moistened filter paper (13). Garlic, mustard and cayenne are too irritant to be testec.l as such (Table 1). At the Finnish Institute of Occupational Health, we pa teh test both garlic and mustarcl at 10% in water, anc.l at 25% in petrolatum. Patch tests with other native spices may also elicit irritant reactions (13, 26) anc.l dilution tests may be neecled. Cinnamon is made from the bark of the cinnamon or cassia tree. Oil of cinnamon contains the allergens cinnamic aldehyc.le and eugenol (Table 1, refs. 13, 27). Cinnamon is a common flavor enhancer, founc.l in tooth- paste (28), chewing gum, tobacco, aperitifs anc.l bitters, vermouth (29), and cola beverages. In addition, it is commonly used as an oc.lor enhancer, and is found in perfumes, after-shave lotions (15), and air deodorizers (30). An ACD can occur in exposed inc.lividuals, parti- cularly bakers (31), candy makers, and cooks. Sensitiza- tion to balsam of Peru can result in cross-sensitivity to cinnamon (1). Cayenne pepper, or Capsicum .fi·utescens, from which the oleoresin of capsicum is derived, is a powerful irritant ancl is used in tear gas (1). Ginger ale and liqueurs flavorec.l with capsicum can produce an ACD (7). The nutmeg tree (Myristica.fi·agrans)produces both nutmeg and mace, which are extensively used in fla- voring foods. The fatty oils of nutmeg are found in soaps ancl perfumes anc.l may be the cause of allergic dermatitis (21). The clove (Syzgium aromaticum) is the unexpan- clecl flower bud of the tree. Oil of cloves is rich in essen- tial oils, especially eugenol ancl vanillin. Eugenol is both a primary irritant and sensitizer and is also found in cinnamon oil and many toothpastes , perfumes, soaps, and mouthwashes. Indians use cloves to flavor the betel nut. It is also used in dental preparations such as cement, impression pastes, ancl surgical packings. It can cause stomatitis ancl allergic eczematous eruptions in dental personnel (32). Cross-reactions to balsam of Pern can be seen. Patch testing can be done with a 10% solution in olive oil or a 5% solution in petrolatum. Oil of clove can be used asa 1-2 o/o alcoholic solution (13, 18). Vanilla is an extract macle from the pod of the vanilla plant, Vanilla plani/'olia. Vanillin is a benzalclehyde, which is the fragrant constituent of vanilla. Clinically, contact dermatitis occurs in individuals who are exposecl through cultivation, tracle, or inclust1y. Symptoms can inclucle edema, e1ythema, rhinitis ancl asthma. Synthetic vanilla is a different compound, and individuals can be sensitized to the natura! spice and not the synthetic compound, and vice versa. For patch testing, a 10% vanillin in petrolatum or a 10% alcoholic extract of vanilla in acetone can be used (18). The sweet bay or bay tree, Laurus nohilis, is native of the Mediterranean and Asia Min or. The usual allergen is laurenobiolicle, which can cross-react with similar chemicals in the Compositae family ancl with magnolia Review 4 --- --- ---- ---- ----------------------- Acta Dermatoven APA Vol 10, 2001, No 1 Review Skin contact reactions to spices Table l. Patch test materials for some spices (see 13, 20, 27). * Ali may irritate when tested as such. In doubtful cases, 25 % and 10 % dilutions in petrolatum may be used (13). ** Not suitable to be tested as such. Dilutions (in petrolatum) may be used: cayenne as 0.5 % (27), paprika as 25 % (13), garlic and mustarcl as 10 % (20). t The presented concentrations do not irritate and are considered safe for patch testing (27). f The test concentrations are given in parentheses. These concentrations are based on the reports of de Groot (27) ancl Niinimiiki (13). (1 , 33). Laure! oil is also used in the textile indust1y to improve the luster of felt hats, and can produce a hatband dermatitis. Laure! leaves, or bay leaves, are used in cooking for their flavor and antioxidant properties, and are found in meat and fish preservation, pickled gherkins, condensed soups, and spiced sauces. Extensive exposure and use have caused sensitization (34,35). Patch testing may be performed with a 2% concentration in petrolatum or 4-5% concentration of essential oil in alcohol (13,18). Acta Dermatoven APA Vol 10, 2001, No 1 ------------------------------------- 5 Skin contact reactions to spices Apple Apricot Apricot stone Banana Grapefru it Kiwi Litchi Lemon Lemon peel Asparagus Beans Cabbage Carrot Castor bean Cauliflower Cele1y Chives Coffee been (green) Coriander Cucumber Dill Endive Garlic Green pepper Leek Balsam of Peru Ben zal dehycle Benzoic acid Cassia (cinnamon) oil Cayenne pepper Caraway Cinnamon Coriander Lime Mango Melon Orange Peach Pineapple flesh Plum Strawbeny Watermelon Lettuce Mustarcl Onion Parsley and parsley root Parsnip Potato Rapeseecl Rocket Rutabaga (Swecle) Shallot Soybean Spinach Stock (Matthiola incana) Tomato Watercress Wingecl bean Cinnamic acid Cinnamic aldehyde Menthol Vanillin Cuny Paprika (capsicum annuum) Thyme Table 2. Plants and spices causing contact urticaria. For references see Amin et al. (8), Ale and Maibach (11). 4. Immediate allergy to spices Paprika, mustard, coriancler, caraway, cayenne, anis, clill, fennel, mustard, celery seecl and parsley are the most conunon causes oftype I skin allergy (13,19), but the list of vegetables and spices causing immediate allergy is extensive (Table 2). Cross-reactions between spices and other vegetables and fruits are common (2,13, 36-39). Positive type I skin reactions to spices and elevated spice-specific serum IgE values (RASTs) have been seen especially in subjects w ith birch or mugwort pollen allergy (13,19) . The term "celery-carrot-mugwort-spice synclrome" bas b een proposed (2, 38, 39) , as these subjects also frequently react to fresh fruits and vegetables. Prick: tests can be performed with native spices as such. The selection of spices used in tests depends on the indivicluals ' exp osure history. Prick tests are performed with native spices as follows: a small amount (2-5 mg) of powderecl spice ancl a drop of saline are first mixed on the skin and then pricked into the skin. The reactions are read after 15 minutes . Reactions with a cliameter of at least 3 mm larger than the negative control (saline) are regarded as positive (13). In cases of fresh materials , prick-prick tests or scratch-chamber tesl~ (13) can be used. The prick tests (size of the wheal) are easier to evaluate than the scratch tests. Deter- mination of spice-specific IgE may also be used when evaluating the clinical significance of the reactions. RAST may be negative in prick test positive cases (40). 5. Treatment and prevention Identification and avoidance of the causative allergen is critical. General principles to treat contact dermatitis should be used (41). However, some studies have shown that despite detection of the allergen and removal of the causative agent from the environment, not ali patients will clear (5). This may be caused by the multifactorial origins of many eruptions , which can include components of irritant and allergic reactions, enclogenous eczema, and unknown factors . R ev i ew 6 - ---------------------------- ------Acta Dermatoven APA Vol 10, 2001, No 1 Revi ew Skin contact reactions to spices R E FE H_ EN C E S l. Chan EF, Mowad C. Contact dermatitis to foods and spices. Am J Contact Dermatitis 1998; 9:71-79. 2. Wiithrich B. Food-induced cutaneous adverse reactions. Allergy 1998; 53 (Suppl 46): 131-135. 3. Adams RM. Dermatitis in food service workers. Allergy Proc 1990: 11: 123-124. 4. Tasti A, Guerra L, Morelli R, Bardazzi F, Fanti PA. Role of foods in the pathogenesis of chronic paronychia. J Am Acad Dermatol 1992; 27: 706-710. 5. Cronin E. Dermatitis of the hands in caterers. Contact Dermatitis 1987; 17: 265-269. 6. Camarasa]F. Foods, in Guin J ( ed): Practical Contact Dermatitis, A Handbook far the Practitioner. New York, NY, McGraw-Hill, Inc. , 1995; pp 519-537. 7. Rietschel RL, Fowler JF Fisher's Contact Dermatitis. Baltimore, MD, Williams & Wilkins 1995. 8. Amin S, Lahti A and Maibach HI. Contact Urticaria Syndrome; CRC Press LLC, Boca Raton, New York, USA 1997 9. Adams RM. Occupational skin disease, 3rd ed, W.B. Saunders Co, Philadelphia 1999; 1-792. 10. Kanerva L, Elsner P, Wahlberg JE, Maibach HI. Handbook of Occupational Dermatology, Springer Verlag, Berlin, Heidelberg,New York 2000; 1-1300. 11. Ale SI, Maibach HI. Occupational contact urticaria. In: Kane1-va L, Elsner P, Wahlberg]E, Maibach HI (eds) Handbook of Occupational Dermatology, Springer Ver!ag, Berlin, Heidelberg, New York 2000; 200-216. 12. DeLeo V. Occupational phototoxicity and photoallergy. In: Kanerva L, Elsner P, WahlbergJE, Maibach HI (eds) Handbook of Occupational Dermatology, Springer Verlag, Berlin, Heidelberg, New York 2000; 314-324. 13. Niinimaki A. Spices. In: Kanerva L, Elsner P, WahlbergJE, Maibach HI ( eds) Handbook of Occupational Dermatology, Springer Verlag, Berlin, Heidelberg, New York 2000; 767-770. 14. Kanerva L. Skin contact reactions to foods and spices (submitted). 15. Dooms-Goossens A, Dubelloy R, Degreef H. Contact and systemic contact-type dermatitis to spices. Dermatol Ciin 1990; 8: 89-93. 16. Niinimaki A. Delayed-type allergy to spices. Contact Dermatitis 1984; 11 :34-40. 17. Hjorth N, Roed-Petersen}. Occupational protein contact dermatitis in food handlers. ContactDermatitis 1976; 2: 28-42. 18. Fisher AA, MitchellJC. Toxicodendron plants and spices. In: Rietschel RL, Fowler JF (eds): Fisher's Contact Dermatitis. Baltimore, MD, Williams & Wilkins 1995; 461-523. 19. Niinimaki A, Hannuksela M. Immediate skin test reactions to spices. Allergy 1981; 36:487-493 20. Kanerva L, Estlander T, Jolanki R. Occupational allergic contact dermatitis from spices. Contact Dermatitis 1996; 35:157-162 21. van den Akker ThW, Roesyanto-Mahadi ID, van Toorenenbergen AW, van Joost Th. Contact allergy to spices. Contact Dermatitis 1990; 22:267-272 22. Foussereau J, Benezra CL, Ourisson G. Contact dermatitis from laurel. I. Glinica! aspects. Trans St Johns Hosp Dermatol Soc 1967; 53:141-146 23. Mobacken H, Fregert S. Allergic contact dermatitis from cardamom. Contact Dermatitis 1975;1: 175- 176 24. Goh CL, Ng SK. Allergic contact dermatitis to Curcuma longa (turmeric). Contact Dermatitis 1987; 17:186 25. Dannaker CJ, White IR. Cutaneous allergy to mustard in salad maker. Contact Dermatitis 1987; 6:212-214 26. Meding B. Skin symptoms among workers in a spice factory. Contact Dermatitis 1993; 29:202-205. 27. de Groot AC. Patch testing. Elsevier, Amsterdam 1994. 28. Magnusson B, Wilkinson OS: Cinnamic aldehyde in toothpaste. Contact Dermatitis 1975; 1:70-76. 29. Fisher AA: Contact dermatitis dne to cinnamon and cinnamic aldehyde. Cutis 1975; 16; 383-388. Acta Dermatoven APA Vol 10, 2001, No 1 --------------------------------- - 7 Skin contact reactions to spices A U T H O R 'S ADDR ESS 30. Nethercott JR, Pilger C, O'Blenis L, Roy AM. Contact dermatitis dne to cinnamic aldehyde induced in a deodorant manufacturing process. Contact Dermatitis 1983; 9: 241-242. 31. Malten KE: Four bakers showing positive patch tests to a number of fragrance materials, which can also be used as tlavors. Acta Dermato Veneorologica 1979; Suppl 59: 117-121. 32. Kanerva L, Estlander T. Dental nurse's occuptional allergic contact dermatitis from eugenol used asa restorative dental material with polymethylmethacrylate. Contact Dermatitis 1998; 38: 339-340. 33. Kanerva L, Estlander T, Alanko K, Jolanki R. Patch test sensitization to Compositae mix, sesquiterpene- lactone mix, Compositae extracts, laurel leaf, Chlorophorin, Mansonone A and dimethoxydalbergione. Am J Contact Dermatitis (in press) 34. Foussereau J, Muller JC, Benezra C: Contact allergy to Frullania and Laurus nobilis: Cross-sensitization and chemical structure ofthe allergens. ContactDermatitis 1975; 1: 223-230. 35. Foussereau J, Benezra C, Ovrisson G. Contact dermatitis from laurel. I. Clinical aspects. Trans St Johns Hosp Dermatol Soc 1967; 53: 141-146. 36. van Toorenenbergen AW, Huijskes-Heins MIE, Leijnse B, Dieges PH. Immunoblot analysis of IgE- binding antigens in spices. Int Arch Allergy Appl Immunol 1988; 86: 117-120. 37. Stager J, Wtithrich B, Johansson SGO. Spice allergy in celery-sensitive patients. Allergy 1991; 46:475- 478. 38. Wtithrich B, Hofer T. Nahrungsmittelallergie: das"Sellerie-Beifuss-Gewurz-Syndrom". Assoziation mit einer Mangofrucht-Allergie? Dtsch Med Wochenschr 1984; 109: 981-986 39. Wtithrich B, Dietschi R. Das "Sellerie-Karotten-Beifuss-Gewtirz-Syndrom": Hauttest- und RAST- Ergebnisse. Schweiz Med Wochenschr 1985; 115:358-364. 40. Niinimaki A, Hannuksela M, Makinen-Kiljunen S. Skin prick tests and in vitro immunoassays with native spices and spice extracts. Ann Allergy 1995; 74:280-286. 41. Kanerva L. Contact dermatitis. In: European Handbook ofDermatological Treatments, Katsan1bas A, Lotti T, eds, Springer-Verlag, Berlin, Heidelberg, New York, Tokyo 1999: 117-126. Lasse J(anerua, MD, PhD, Projessor and Chiej Section oj Dermatology Finnish Institute oj Occupational Health, Topeliuksenkatu 41 aA, FIN- 00250 Helsinki, Finland. E-mail: Lasse.l(anerua@occuphealthfi Review 8 ---- --- - - ------ - ----- - - --- - - - - ----Acta Dermatoven APA Vol 10, 2001, No 1