T he thin-layer rapid use epicutaneous (T.R.U.E.) Test of 23 common allergens is a valuable, first-line screening tool used by many dermatologists. Although the test focuses on common allergens, frequent questions have arisen from colleagues and patients as to where exactly a specific allergen is derived or what products should be avoided by patients who are allergic to that allergen. With this in mind, this column was developed to provide more educational information about the T.R.U.E. Test allergens. A rich, interesting history accompanies each of the 23 allergens, and understanding these historic perspectives can help to better educate patients. Each column will also highlight products patients should avoid when allergic to a specific allergen. Contact Dermatides Allergic contact dermatitis (ACD) is an important disease with high impact both in terms of patient morbidity and economics. The contact dermatides include allergic contact dermatitis, irritant contact dermatitis and contact urticaria. Irritant contact dermatitis, the most common form, accounts for approximately 80% of environmental-occupational based dermatoses. Contact urticaria (wheal and flare reaction) represents an IgE and mast cell-mediated immediate-type hypersensitivity reaction that can lead to anaphylaxis, the foremost example of this would be latex hypersensitivity. While this is beyond the scope of this section, we acknowledge this form of hypersensitivity due to the severity of the potential reactions and direct the reader to key sources.1,2 The primary focus of this section is to highlight the educational component of allergic contact dermatitis. Clinical Illustration Our patient presented with a history of recently worsening atopic dermatitis in a generalized distribution. Our first plan of action was to obtain a detailed history of allergen exposure because this is a crucial part in the evaluation of the ACD patient. Upon questioning the patient, we quickly learned that watching television, while eating pizza and drinking cola, dominated the patient’s leisure time. These points are important because it so happens that such common foods are very rich in an ingredient called Balsam of Peru (BOP). History of Balsam of Peru Balsam of Peru is a dark brown, complex, viscous fluid that is exuded from the wounded mature Myroxylon balsamum tree. The vanilla and cinnamon aroma can be attributed to the volatile oil cinnamein, a combination of cinnamic acid, benzoyl cinnamate, benzoyl benzoate, benzoic acid, vanillin, and nerodilol.3 El Salvador, the main exporter of BOP, produces approximately 50 metric tons annually. The cause of 1.6% to 10.8% of all ACD cases worldwide, BOP is one of the five most prevalent allergens detected by both the T.R.U.E. test and the North American Contact Dermatitis Group (NACDG).4 The three most frequently reported sites of dermatitis are the hands, face and anogenital regions.5 The first cutaneous allergic manifestation involving BOP was described by Mögling in 1880 as an urticarial reaction to a BOP-containing ointment for the treatment of scabies.6 Balsam of Peru was named such because it was originally assembled and shipped to Europe from the port of Callao in Peru. The sap was used as a highly prized sacramental ointment by the Spanish clergy, leading to the papal decree of 1562 and 1571 that forbid the destruction of the balsam trees. The medical field was also aware of Balsam’s early applications. Since the times of the Incan Empire, Peruvians have used balsam to relieve fevers, colds, coughs, bronchitis, and infections. The Aztecs, in Mexico, cultivated the tree in their royal gardens and made compresses with the mashed leaves to speed the healing of wounds.7 Common Uses for this Ingredient The modern usage of BOP is divided between the pharmaceutical, cosmetic and flavoring industries. Because of its mild bactericidal action and capillary-bed stimulant effects, BOP is widely used in topical medicines for wounds, burns and hemorrhoids. In accordance, BOP was recently reported to be the most common allergen in patients with past or present leg ulcerations.8 An increasing number of ACD reactions to BOP have been seen in infancy and childhood, likely due to more perfumes and baby care products containing fragrances that are applied under occlusion to the “diaper area.”9 The cosmetic industry widely uses this ingredient for perfumes and sunscreening agents. A very important exposure to BOP occurs because this ingredient is widely used in foods (Table 1).9 Cross-reactions with BOP may occur to colophony (rosin), balsam of Tolu, wood and coal tars, resorcin monobenzoate (RMB), turpentine, propolis, coniferyl benzoate, benzoin, and tomatoes, orange peel and clove (Table II). Occupational sensitization is widespread, including dentists (dental cement), bakers (flavoring agents), beekeepers (to beeswax), painters (turpentine), violinist (rosin), and laboratory technicians (fixatives used in the preparation of histology slides).9,10 Testing for BOP Sensitivity Patch testing for BOP allergy can be accomplished with the T.R.U.E. test [site #10]. The T.R.U.E test recognizes only 23 of the more than 3,700 possible allergens that can cause allergic contact dermatitis. Therefore, keep in mind that this test is a mere screening tool. In cases where the TRUE test is inadequate, the patient should undergo comprehensive patch testing. The availability of comprehensive patch testing is limited, as suggested by the fact that the American Contact Dermatitis Society (ACDS) has roughly 450 members compared to the American Academy of Dermatology’s 14,000 members. Patch testing support and patient education materials are available from the ACDS through the newly developed Contact Allergen Replacement Database (C.A.R.D.) The Value of this Patient Case Our patient, who unknowingly was ingesting a diet high in BOP, underscores the importance of appropriate patch testing and subsequent patient education. This patient dramatically improved on a BOP-avoidance regimen, consistent with the fact that the mainstay of treatment for allergic contact dermatitis is avoidance.
Focus on T.R.U.E. Test Allergen #10: Balsam of Peru
T he thin-layer rapid use epicutaneous (T.R.U.E.) Test of 23 common allergens is a valuable, first-line screening tool used by many dermatologists. Although the test focuses on common allergens, frequent questions have arisen from colleagues and patients as to where exactly a specific allergen is derived or what products should be avoided by patients who are allergic to that allergen. With this in mind, this column was developed to provide more educational information about the T.R.U.E. Test allergens. A rich, interesting history accompanies each of the 23 allergens, and understanding these historic perspectives can help to better educate patients. Each column will also highlight products patients should avoid when allergic to a specific allergen. Contact Dermatides Allergic contact dermatitis (ACD) is an important disease with high impact both in terms of patient morbidity and economics. The contact dermatides include allergic contact dermatitis, irritant contact dermatitis and contact urticaria. Irritant contact dermatitis, the most common form, accounts for approximately 80% of environmental-occupational based dermatoses. Contact urticaria (wheal and flare reaction) represents an IgE and mast cell-mediated immediate-type hypersensitivity reaction that can lead to anaphylaxis, the foremost example of this would be latex hypersensitivity. While this is beyond the scope of this section, we acknowledge this form of hypersensitivity due to the severity of the potential reactions and direct the reader to key sources.1,2 The primary focus of this section is to highlight the educational component of allergic contact dermatitis. Clinical Illustration Our patient presented with a history of recently worsening atopic dermatitis in a generalized distribution. Our first plan of action was to obtain a detailed history of allergen exposure because this is a crucial part in the evaluation of the ACD patient. Upon questioning the patient, we quickly learned that watching television, while eating pizza and drinking cola, dominated the patient’s leisure time. These points are important because it so happens that such common foods are very rich in an ingredient called Balsam of Peru (BOP). History of Balsam of Peru Balsam of Peru is a dark brown, complex, viscous fluid that is exuded from the wounded mature Myroxylon balsamum tree. The vanilla and cinnamon aroma can be attributed to the volatile oil cinnamein, a combination of cinnamic acid, benzoyl cinnamate, benzoyl benzoate, benzoic acid, vanillin, and nerodilol.3 El Salvador, the main exporter of BOP, produces approximately 50 metric tons annually. The cause of 1.6% to 10.8% of all ACD cases worldwide, BOP is one of the five most prevalent allergens detected by both the T.R.U.E. test and the North American Contact Dermatitis Group (NACDG).4 The three most frequently reported sites of dermatitis are the hands, face and anogenital regions.5 The first cutaneous allergic manifestation involving BOP was described by Mögling in 1880 as an urticarial reaction to a BOP-containing ointment for the treatment of scabies.6 Balsam of Peru was named such because it was originally assembled and shipped to Europe from the port of Callao in Peru. The sap was used as a highly prized sacramental ointment by the Spanish clergy, leading to the papal decree of 1562 and 1571 that forbid the destruction of the balsam trees. The medical field was also aware of Balsam’s early applications. Since the times of the Incan Empire, Peruvians have used balsam to relieve fevers, colds, coughs, bronchitis, and infections. The Aztecs, in Mexico, cultivated the tree in their royal gardens and made compresses with the mashed leaves to speed the healing of wounds.7 Common Uses for this Ingredient The modern usage of BOP is divided between the pharmaceutical, cosmetic and flavoring industries. Because of its mild bactericidal action and capillary-bed stimulant effects, BOP is widely used in topical medicines for wounds, burns and hemorrhoids. In accordance, BOP was recently reported to be the most common allergen in patients with past or present leg ulcerations.8 An increasing number of ACD reactions to BOP have been seen in infancy and childhood, likely due to more perfumes and baby care products containing fragrances that are applied under occlusion to the “diaper area.”9 The cosmetic industry widely uses this ingredient for perfumes and sunscreening agents. A very important exposure to BOP occurs because this ingredient is widely used in foods (Table 1).9 Cross-reactions with BOP may occur to colophony (rosin), balsam of Tolu, wood and coal tars, resorcin monobenzoate (RMB), turpentine, propolis, coniferyl benzoate, benzoin, and tomatoes, orange peel and clove (Table II). Occupational sensitization is widespread, including dentists (dental cement), bakers (flavoring agents), beekeepers (to beeswax), painters (turpentine), violinist (rosin), and laboratory technicians (fixatives used in the preparation of histology slides).9,10 Testing for BOP Sensitivity Patch testing for BOP allergy can be accomplished with the T.R.U.E. test [site #10]. The T.R.U.E test recognizes only 23 of the more than 3,700 possible allergens that can cause allergic contact dermatitis. Therefore, keep in mind that this test is a mere screening tool. In cases where the TRUE test is inadequate, the patient should undergo comprehensive patch testing. The availability of comprehensive patch testing is limited, as suggested by the fact that the American Contact Dermatitis Society (ACDS) has roughly 450 members compared to the American Academy of Dermatology’s 14,000 members. Patch testing support and patient education materials are available from the ACDS through the newly developed Contact Allergen Replacement Database (C.A.R.D.) The Value of this Patient Case Our patient, who unknowingly was ingesting a diet high in BOP, underscores the importance of appropriate patch testing and subsequent patient education. This patient dramatically improved on a BOP-avoidance regimen, consistent with the fact that the mainstay of treatment for allergic contact dermatitis is avoidance.
T he thin-layer rapid use epicutaneous (T.R.U.E.) Test of 23 common allergens is a valuable, first-line screening tool used by many dermatologists. Although the test focuses on common allergens, frequent questions have arisen from colleagues and patients as to where exactly a specific allergen is derived or what products should be avoided by patients who are allergic to that allergen. With this in mind, this column was developed to provide more educational information about the T.R.U.E. Test allergens. A rich, interesting history accompanies each of the 23 allergens, and understanding these historic perspectives can help to better educate patients. Each column will also highlight products patients should avoid when allergic to a specific allergen. Contact Dermatides Allergic contact dermatitis (ACD) is an important disease with high impact both in terms of patient morbidity and economics. The contact dermatides include allergic contact dermatitis, irritant contact dermatitis and contact urticaria. Irritant contact dermatitis, the most common form, accounts for approximately 80% of environmental-occupational based dermatoses. Contact urticaria (wheal and flare reaction) represents an IgE and mast cell-mediated immediate-type hypersensitivity reaction that can lead to anaphylaxis, the foremost example of this would be latex hypersensitivity. While this is beyond the scope of this section, we acknowledge this form of hypersensitivity due to the severity of the potential reactions and direct the reader to key sources.1,2 The primary focus of this section is to highlight the educational component of allergic contact dermatitis. Clinical Illustration Our patient presented with a history of recently worsening atopic dermatitis in a generalized distribution. Our first plan of action was to obtain a detailed history of allergen exposure because this is a crucial part in the evaluation of the ACD patient. Upon questioning the patient, we quickly learned that watching television, while eating pizza and drinking cola, dominated the patient’s leisure time. These points are important because it so happens that such common foods are very rich in an ingredient called Balsam of Peru (BOP). History of Balsam of Peru Balsam of Peru is a dark brown, complex, viscous fluid that is exuded from the wounded mature Myroxylon balsamum tree. The vanilla and cinnamon aroma can be attributed to the volatile oil cinnamein, a combination of cinnamic acid, benzoyl cinnamate, benzoyl benzoate, benzoic acid, vanillin, and nerodilol.3 El Salvador, the main exporter of BOP, produces approximately 50 metric tons annually. The cause of 1.6% to 10.8% of all ACD cases worldwide, BOP is one of the five most prevalent allergens detected by both the T.R.U.E. test and the North American Contact Dermatitis Group (NACDG).4 The three most frequently reported sites of dermatitis are the hands, face and anogenital regions.5 The first cutaneous allergic manifestation involving BOP was described by Mögling in 1880 as an urticarial reaction to a BOP-containing ointment for the treatment of scabies.6 Balsam of Peru was named such because it was originally assembled and shipped to Europe from the port of Callao in Peru. The sap was used as a highly prized sacramental ointment by the Spanish clergy, leading to the papal decree of 1562 and 1571 that forbid the destruction of the balsam trees. The medical field was also aware of Balsam’s early applications. Since the times of the Incan Empire, Peruvians have used balsam to relieve fevers, colds, coughs, bronchitis, and infections. The Aztecs, in Mexico, cultivated the tree in their royal gardens and made compresses with the mashed leaves to speed the healing of wounds.7 Common Uses for this Ingredient The modern usage of BOP is divided between the pharmaceutical, cosmetic and flavoring industries. Because of its mild bactericidal action and capillary-bed stimulant effects, BOP is widely used in topical medicines for wounds, burns and hemorrhoids. In accordance, BOP was recently reported to be the most common allergen in patients with past or present leg ulcerations.8 An increasing number of ACD reactions to BOP have been seen in infancy and childhood, likely due to more perfumes and baby care products containing fragrances that are applied under occlusion to the “diaper area.”9 The cosmetic industry widely uses this ingredient for perfumes and sunscreening agents. A very important exposure to BOP occurs because this ingredient is widely used in foods (Table 1).9 Cross-reactions with BOP may occur to colophony (rosin), balsam of Tolu, wood and coal tars, resorcin monobenzoate (RMB), turpentine, propolis, coniferyl benzoate, benzoin, and tomatoes, orange peel and clove (Table II). Occupational sensitization is widespread, including dentists (dental cement), bakers (flavoring agents), beekeepers (to beeswax), painters (turpentine), violinist (rosin), and laboratory technicians (fixatives used in the preparation of histology slides).9,10 Testing for BOP Sensitivity Patch testing for BOP allergy can be accomplished with the T.R.U.E. test [site #10]. The T.R.U.E test recognizes only 23 of the more than 3,700 possible allergens that can cause allergic contact dermatitis. Therefore, keep in mind that this test is a mere screening tool. In cases where the TRUE test is inadequate, the patient should undergo comprehensive patch testing. The availability of comprehensive patch testing is limited, as suggested by the fact that the American Contact Dermatitis Society (ACDS) has roughly 450 members compared to the American Academy of Dermatology’s 14,000 members. Patch testing support and patient education materials are available from the ACDS through the newly developed Contact Allergen Replacement Database (C.A.R.D.) The Value of this Patient Case Our patient, who unknowingly was ingesting a diet high in BOP, underscores the importance of appropriate patch testing and subsequent patient education. This patient dramatically improved on a BOP-avoidance regimen, consistent with the fact that the mainstay of treatment for allergic contact dermatitis is avoidance.
