Australasian Journal of Dermatology (2002) 43, 211213

CAS E REPORT

Allergic contact dermatitis following exposure to essential oils

Narelle Bleasel,1 Bruce Tate1 and Marius Rademaker2
1

Skin and Cancer Foundation, Carlton, Victoria, Australia, and 2 Health Waikato, Hamilton, New Zealand

SUMMARY
Allergic contact dermatitis from the topical use of essential oils is not widely recognized as an occupational hazard. Four cases of allergic contact dermatitis to essential oils occurring in three aromatherapists and one chemist with a particular interest in aromatherapy are described. All presented with predominantly hand dermatitis and demonstrated sensitization to multiple essential oils. One patient developed a recurrence of cutaneous symptoms following ingestion of lemongrass tea. Workers within this industry should be aware of the sensitization potential of these products and the risk of limiting their ability to continue employment. Key words: Bulgarian rose oil, hand dermatitis, lavender oil, natural therapist, occupational skin disease, ylang ylang oil.

and sesquiterpene alcohols, esters, ethers, aldehydes, ketones and oxides.1 Typically, each oil has several compounds from each major chemical group.1 The spectrum of reported skin reactions to essential oils includes allergic contact dermatitis, irritant contact dermatitis, phototoxic reactions and contact urticaria.35 We present four cases of hand dermatitis as a result of allergic contact dermatitis following exposure to essential oils.

CASE REPORTS Case 1

A 52-year-old female masseur and aromatherapist presented with a 12-month history of hand and later forearm dermatitis. The rash improved substantially when she was absent from work and recurred upon her returning. Standard patch testing was performed using aluminium Finn chambers with readings at 48 and 96 hours, to an extended standard series, a cosmetic series, a fragrance series and her own massage oils. The positive reactions are presented in Table 1. The aromatherapist subsequently developed a small area of dermatitis on her forearm following ingestion of lemongrass tea and Thai food.

INTRODUCTION
The exposure to essential, or volatile, oils in an occupational setting is increasing with the burgeoning popularity of natural therapies in Anglo-Saxon cultures. Aromatherapy is the use of essential oils topically or by inhalation to promote physical and psychological well-being.1 Essential oils are aromatic substances that are extracted from many different plants and a small number of animals, or that can be synthesized from coal and petrolatum.2 The oil can be extracted from plants and owers by several methods including distillation, extraction, eneurage, maceration and expression.2 The composition of essential oils is highly variable. Each oil may have over 100 constituents; the same botanical species may produce oils containing differing components and concentrations.1 The principal constituents of essential oils are monoterpene and sesquiterpene hydrocarbons, monoterpene

Case 2
A 46-year-old female masseur and aromatherapist presented with a 3-year history of hand and forearm dermatitis. The rash improved upon cessation of her employment. She had a past history of hayfever and a family history of atopy. Standard patch testing was performed using aluminium Finn chambers with readings at 48 and 96 hours to an extended standard series, a cosmetic series, a fragrance series, a limited plant series and her own massage oils. The positive reactions are presented in Table 1. In addition, the patient demonstrated a positive patch-test reaction to her own massage oil, which contained a mix of almond, ylang ylang, neroli, sandalwood and frankincense oils.

Case 3
Correspondence: Dr B Tate, Skin and Cancer Foundation, 95 Rathdowne St, Carlton, Vic. 3053, Australia. Narelle Bleasel, MB BS. Bruce Tate, FACD. Marius Rademaker, FRACP. Submitted 22 October 2001; accepted 15 January 2002.

A 45-year-old natural therapist presented with a 3-year history of hand dermatitis, which extended to involve her face and neck 2 weeks prior to presentation. The eruption resolved completely while on a 2-week holiday. Patch testing to the

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N Bleasel et al. when combined in an oil mixture.1,5 This is known as the quelching effect.1,5 Indeed, a degradation product may be the sensitizing agent.1,3 The four cases presented developed a delayed type allergy to essential oils following exposure in an occupational setting. In all cases, multiple sensitizations were demonstrated. Case 1 displayed positive patch-test reactions to several essential oils that she had not previously been exposed to, including palmarosa, frankincense, rose, neroli and myrrh. Linalool was a common constituent amongst this group of sensitizing oils, with the exception of myrrh, implicating cross-reactivity.17,18 Of note, this patient had a positive patchtest reaction to lemongrass and described a recurrence of dermatitis following ingestion of lemongrass-containing foods. The phenomenon of systemic contact dermatitis has previously been described in relation to Matricaria chamomilla tea.19 Case 2 exhibited sensitivity to geraniol, a component of lavender, rose, geranium, ylang ylang, lemongrass, cananga, sandalwood and neroli.17,18 This may account for her sensitivity to these products. In addition this patient displayed sensitivity towards peppermint, laurel and yarrow, products which do not contain geraniol.17,18 Limonene is a common component in this second group of oils; however, sensitivity to this compound was not tested.17,18 Geraniol is a common constituent of the oils case 3 developed sensitization reactions to;17,18 however, the patient did not exhibit sensitivity to geraniol. Similarly, the positive reactions seen in case 4 could be accounted for by sensitivity to geraniol; however, no primary reaction to geraniol was present. Of note, three of the four cases presented had positive patch-test reactions to fragrance mix. The constituents of fragrance mix are cinnamic alcohol, cinnamic aldehyde, -amyl cinnamic aldehyde, eugenol, isoeugenol, geraniol, hydroxycitronella and oak moss.20 Six of these eight fragrance ingredients are also components of essential oils (including cinnamic alcohol, cinnamic aldehyde, eugenol, isoeugenol, geraniol).4 Fragrance mix is a common allergen, with approximately 1% of the unselected population demonstrating sensitivity.21 Patients with positive patch-test reactions to fragrance mix often react to essential oils. One study demonstrated that 57% of patients with positive reactions to fragrance mix also reacted to one or more essential oils.22 However, testing solely with fragrance mix or its constituents will not reliably detect all patients allergic to essential oils. Patients can be tested to the commercially available allergens in the Chemotechnique fragrance series. The use of essential oil-based products in peoples homes is also now popular and leading to reports of allergic contact dermatitis.2325 Many cosmetics and perfumes contain essential oils and are likely to be important allergens.5,20,22,26 In Japan, an increase in the frequency of positive patch tests to lavender oil was reported between 1990 and 1998.25 A telephone survey of these patients suggested the main source of exposure to the lavender allergens was products containing dried lavender owers. These cases highlight the importance of allergic contact dermatitis associated with essential oil exposure in an occupational setting. It appears that multiple sensitizations are a common occurrence. Therefore, avoidance of a single

Table 1

Results of patch tests Case 1 + + + + + + + + + + + Case 2 + + + + NT + NT + + NT + + + + + Case 3 NT + NT NT NT NT NT NT NT + + NT Case 4 + + + NT + NT NT NT NT NT NT NT + + NT +

Test substance Fragrance mix Cananga oil 2.0% Geraniol 2.0% Geranium oil Bourbon 2.0% Frankincense 5.0% Lavender absolute 2.0% Lavender oil 2.0% Laurel oil 2.0% Lemongrass oil 2.0% Myrrh 5.0% Neroli oil 2.0% Palmarosa 5.0% Peppermint oil 2.0% Rose oil, Bulgarian 2.0% Sandalwood oil 2.0% Yarrow Ylang ylang oil 2.0%

+, positive reaction; , negative reaction; NT, not tested.

European standard series (Chemotechnique, Malmo, Sweden), antimicrobials, an extended fragrance series and her own massage oils was performed using IQ chambers (Chemotechnique), with readings at 48 and 96 hours. The positive reactions are presented in Table 1.

Case 4
A 29-year-old analytical chemist, with a part-time occupational interest in aromatherapy and massage, presented with a 1-month history of hand dermatitis. The rash became more widespread to involve her face and neck prior to presentation. Relevant past history included hayfever and scabies. Patch testing to the European standard series (Chemotechnique), a cosmetic series, a fragrance series, and the patients own massage oils was performed using IQ chambers (Chemotechnique) with readings at 48 and 96 hours. The positive reactions are presented in Table 1. Reactions were graded according to the International Contact Dermatitis Research Group grading system.

DISCUSSION
The frequency of allergic contact dermatitis associated with essential oil usage is unknown and at present there have been only limited reports of this association in the natural therapy industry.69 This may represent low incidence of sensitization to these compounds, or a failure to recognize allergic contact dermatitis within this occupation and subsequent underreporting. Allergic contact dermatitis related to essential oils has been reported in several other occupational groups, including bar workers,10 citrus fruit pickers,11 a hairdresser,12 a physiotherapist,13 a beautician14 and manufacturers of cosmetics.15,16 Determining the sensitizing agent responsible for skin reactions associated with an essential oil is difcult, because of the many components and their variable concentrations within an oil.1 In addition, the components of an essential oil often undergo complex interactions that result in reducing the sensitization potential of an individual compound

Contact dermatitis to essential oils oil is unlikely to prevent further episodes of allergic contact dermatitis. In addition, the concurrent reaction to fragrance mix may pose further limitations on product selection. Employees within the aromatherapy and masseur industry should be aware of the sensitization potential of the oils that they use in their workplace. Sensitization to essential oils may have serious ramications, as the employees may be unable to continue in their chosen eld of work. It is also necessary to consider allergy to essential oils in clients of aromatherapists and people using them at home.

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