Understanding Fragrance Allergy, Is Fragrance-free Always Necessary?

May 1, 2014 | Contact Author | By: Garrett Coman and Nicholas Blickenstaff, University of California San Francisco, San Francisco, USA, and University of Utah, Salt Lake City, USA; Ashley Edwards, Touro University, Vallejo, CA, USA; Howard I. Maibach, MD, University of California San Francisco, San Francisco, USA
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Title: Understanding Fragrance Allergy, Is Fragrance-free Always Necessary?
fragrance allergyx patch testx use testx repeat open application testx dermatitisx
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Keywords: fragrance allergy | patch test | use test | repeat open application test | dermatitis

Abstract: This article reviews studies to diagnose allergic contact dermatitis due to fragrance, including a patch test designed to measure such. Limitations of patch testing, the relevance of fragrance concentration in products, use testing of common consumer products, and dermatologist recommendations to manage fragrance contact allergy also are discussed.

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HI Maibach, G Coman, N Blickenstaff and A Edwards, Understanding Fragrance Allergy, Is Fragrance-free Always Necessary? Cosm & Toil 129(4) 32-37 (May 2014)

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Fragrances have become ubiquitous in skin and hair care products to appeal to the consumer’s senses. However, fragrances have been associated with allergic contact dermatitis in applications including: unspecified leave-on products, sun tan lotion, deodorants, scented lotion, unspecified rinse-off products, fine fragrances, shampoo, liquid soap, aftershave, lipstick, sunscreen, hair styling products, shaving foam, mascara, hair dye, eye shadow and makeup cream. While some dermatologists recommend avoiding all fragrances yielding positive patch test results, it has become increasingly difficult to avoid all fragrances and in the end, may be unnecessary for the patch test positive patient.

To identify dermatitis caused by fragrance, a patch test for common aromatic allergens was designed in which two fragrance mixes using putative common allergens served as screens. Fragrance Mix #1 (FM1) was developed from the fragrances used in an antifungal cream that had caused an allergic contact dermatitis epidemic. It comprised: Evernia prunastri (oak moss), isoeugenol, cinnamyl alcohol, eugenol, cinnamal, geraniol, α-amylcinnamal and hydroxycitronellal. Fragrance Mix #2 (FM2), a later attempt5 to identify fragrance allergens, consisted of hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC), farnesol, citral, hexyl cinnamal, citronellol and coumarin. These materials are considered EU fragrance allergens and have been used in fragrance allergy testing reported in the literature, which are reviewed here.

Preliminary Questionnaire

The diagnosis of a fragrance contact allergy always starts with a detailed medical history. Schollhammer et al. developed a questionnaire to determine if consumers had a “certain, probable or possible” allergy to fragrances based on their recollection of adverse reactions to perfumes or perfumed products. In this questionnaire, the “certain” allergy included an itching dermatitis reaction to at least one fine perfume or aftershave, and reactions to other perfumed products. The “probable” allergy involved reacting to one or more perfumed products (e.g., deodorant) but no specific perfume being identified as causing the clinical reaction. The “possible” allergy meant reacting to various cosmetic products with and without perfume, where materials other than fragrance constituted the possible cause of the reaction. Finally, those identified without a fragrance allergy had never reacted to a perfumed material.

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Table 1. Fragrance Mix Allergens and Additional EU Allergens

Table 1. Fragrance Mix Allergens and Additional EU Allergens

Materials considered EU fragrance allergens, along with their FM designation; these mixes have been used in fragrance allergy testing reported in the literature.

Figure 1. Typical allergic contact dermatitis of the axilla

Figure 1. Typical allergic contact dermatitis of the axilla

Typical allergic contact dermatitis of the axilla due to a deodorant fragrance; Note: The fold of the axilla is partly spared; a classic observation believed to be due to axillary sweating diluting the allergen.

Figure 2. Positive patch test reaction

Figure 2. Positive patch test reaction

Positive patch test reaction scored as ++ according to International Contact Dermatitis Research Group recommendations

Biography: Howard I. Maibach, MD, University of California, San Francisco

Howard I. Maibach, MD, is a professor of derma­tology at the University of California School of Medicine, San Francisco. His labor­atory has been interested in and has published exten­sively on derm­ato­pharma­cology and dermatotoxicology.

Guest Contributors

Garrett Coman is a senior medical student at the University of Utah, currently completing a research fellowship at Maibach’s lab. He has a background in economics and biomedical engineering, with a focus on medical innovation and research in dermatology.

Nick Blickenstaff is a senior medical student at the University of Utah, with a background in psychology and biomedical engineering. He is currently completing a research fellowship at Maibach’s lab, performing research focused on dermatopharmacology and dermatotoxicology.

Ashley Edwards is a senior medical student at Touro University California. She plans to pursue pediatric dermatology. After graduating from Columbia University in chemical engineering and visual arts, she worked in medical ethics and public health research at Columbia University Medical Center.

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