Contact allergy to propolis
What is propolis?
Propolis is the glue made by honey bees to build, repair and protect their hives. It consists of partially digested resins from a variety of tree buds and barks mixed with bees wax. In Europe, it derives mainly from poplar buds, but conifers are also used. Propolis therefore is a complex mixture comprising balsams and resins, waxes, essential oils, pollen and cinnamyl alcohol, vitamins A, B, C and E, flavanoids and minerals.
A number of other substances that are related to propolis may be listed as ingredients, particularly of cosmetics. Cera flava is the yellow wax produced from honeycomb. Cera alba is the bleached form of cera flava. It is used as an emulsifier and thickening agent in cosmetics and as a food additive (E901) for coating and glazing candy and fresh fruit. Other propolis-related substances include propolis cera, beeswax acid and synthetic beeswax.
Who gets contact allergic reactions to propolis and why?
Propolis is an increasingly important allergen, with European studies reporting positive patch test rates of 1.2 to 6.6%. In one series from Finland, the rate increased from 0.5% in 1995-7 to 1.4% in 2000-2. Another study in children reported an increase from 2% to 13.7% between 1995 and 2002; 75% of the patch test-positive children had used a natural product or alternative medicine remedy. In a 2010 Polish patch test study of children with chronic recurrent eczema and atopy, a positive propolis patch test was recorded in 16.5% of children aged 7-8 years and 5.4% of adolescents aged 16-17 years. Propolis was the second most common positive patch test allergen after nickel in children and the fourth most common in adolescents.
Exposure to propolis and propolis-related substances can occur in the following settings:
- beekeepers – propolis allergy can develop after many years of exposure. In one study the average exposure time before developing propolis allergy was 9.5 years (range 0.1-35 years).
- violin makers and violinists – propolis has been a component of Italian varnish for centuries.
- shoemaker – beeswax is used for the seams of handmade boots and may be contaminated with propolis.
- timber cutters – including forestry workers and farmers, specifically cutting poplar trees.
- artist – moulding in beeswax
- Therapeutic use
Propolis has been widely used in natural therapeutic products because of its purported antiseptic, anti-inflammatory, anaesthetic and anti-oxidant properties. Propolis is advocated as a steroid- and chemical-free natural alternative. Natural therapeutic products containing propolis include mouth lozenges, cough syrups, ointments, lotions, drops and oral pills. Propolis has been commonly implicated in contact allergies complicating chronic venous insufficiency (5%) and anogenital disease (2.5%).
- Honey – although propolis is usually completely removed it may be added for its purported therapeutic effect
- Gloss – on fruit, candies, chewable vitamins, chewing gums
- Stiffening agent
- ointments and creams
- Modified-release oral preparations
- To adjust the melting point of suppositories.
Biocosmetics and biotherapeutics appear to be the most common source of exposure to propolis in those sensitized to it.
The major allergens in propolis derived from poplar buds are caffeates. 3-Methyl-2-butenyl caffeate and phenylethyl caffeate are the main sensitizers. Benzyl caffeate, geranyl caffeate, benzyl salicylate, benzyl cinnamate, methyl cinnamate, ferulic acid and tectochrysin are also sensitizers present in propolis.
Propolis allergy often cross-reacts with Myroxylon pereirae (balsam of Peru) as there are 13 known constituents in common. Other recognised crossreactions due to shared ingredients (commonly cinnamic acid, cinnamyl alcohol, vanillin) include:
- Fragrance mix I
- Carnauba wax (from the Brazilian carnauba palm) – used as an edible gloss finish.
Crossreaction with bees wax is uncommon, but can occur, possibly due to contamination with propolis.
Contact with propolis can be direct or, less commonly, airborne.
- Itching, burning, pain
- Localised swelling eg of the lips, tongue
- Localised rash
- hand dermatitis – common presentation
- psoriasiform (like palmoplantar psoriasis)
- redness, tiny bumps, itching
- eczematous rash around the mouth (perioral eczema)
- cheilitis – redness, scaling and crusting of the lips
- stomatitis – including mouth ulcers
- fiddler's neck
- facial redness, itch and swelling if due to airborne contact
- hand dermatitis – common presentation
- Throat complaints – difficulty swallowing or speaking
- Systemic symptoms such as shortness of breath
- Autosensitization dermatitis (rash at a distant site from primary contact) has been reported.
Reactions begin within hours to days of exposure in a previously sensitized patient. Initial sensitisation takes 10-15 days.
How is propolis allergy diagnosed?
The diagnosis of propolis allergy is made by patch testing with propolis 10% in petrolatum and the likely source ‘as is’ or diluted eg honey, cosmetic or therapeutic formulation. A flare of the original dermatitis has been reported in association with positive patch test reactions.
Avoidance of propolis-containing products results in resolution of the reaction, but sometimes a further unidentified source of propolis exposure causes persistence of milder symptoms. It is therefore important to re-assess should the contact allergy symptoms not settle completely despite avoidance of the original source of propolis.
Beekeepers with allergic contact dermatitis of the hands due to propolis may be able to continue working with hives by wearing rubber or leather gloves.
In one case, ingestion of propolis-enriched honey as a capsule had no effect despite cheilitis/perioral eczema and positive patch test to honey and propolis.
Patients with known allergies to conifer, poplar, salicylates and Myroxylon pereirae are advised to avoid propolis due to shared allergenic constituents. It is important to be aware of the names of propolis-related substances as these also should be avoided.