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Fragrance allergy

Author: Elaine Luther, Medical Student, Ross University School of Medicine, Barbados, West Indies. Medical Editor: Dr Helen Gordon, Auckland, New Zealand. DermNet NZ Editor in Chief, Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. July 2020.


What is a fragrance allergy?

Fragrance allergy refers to the development of allergic contact dermatitis to a fragrance chemical.

Fragrances and perfumes can either be made from a natural extract or made artificially. They produce a pleasant scent or disguise the unpleasant scent of a product.

Allergy requires prior sensitisation to the fragrance chemical. Further contact of the chemical with the skin causes a delayed hypersensitivity reaction (type IV) in hours to days after exposure.

Who gets a fragrance allergy?

Fragrance allergy is common and is believed to affect around 1% of adults [1]. Rates in children and adolescents are around 1.8% [1]. Fragrance allergy is second only to nickel allergy as a cause of allergic contact dermatitis [2,3].

Allergic contact dermatitis occurs as frequently in people with and without a history of atopic dermatitis [4].

Fragrances are not limited to perfumes and cosmetics. They are also found in:

  • Personal care products such as body wash, lotions, shampoos, conditioners, deodorants, baby wipes, and sanitary pads
  • Household products such as laundry detergents, fabric softener, air freshener, cleaning agents, and toilet paper
  • Flavours added to food and drinks, lipsticks, lip balms, and toothpaste.

Anyone who uses these products can become sensitised to them over time.

What causes fragrance allergy?

A European Scientific Committee on Consumer Safety review of fragrances in 2011 listed 82 that had been established as contact allergens including 54 synthetic chemicals and 28 natural extracts [1].

Among the most common are the 15 fragrances that can be identified by patch testing with balsam of Peru (BoP), Fragrance Mix I (FM I), and Fragrance Mix II (FM II).

Patch testing
 

What are the clinical features of fragrance allergy?

The clinical features of fragrance allergy are in keeping with a delayed hypersensitivity reaction. Dermatitis occurs where there has been direct contact with the fragrance allergen.

  • In women, the hands, face, and neck are most commonly affected.
  • In men, the hands, face, and lower legs are most often affected [1].
  • The fragrance chemical can be transferred to an unexpected site, for example, via the hands onto the face.
  • Other locations affected include perianal skin if wet wipes with fragrance are used, and the scalp if the responsible fragrance is in a shampoo.

Typically, fragrance allergy presents as scaly erythematous plaques.

  • There can be significant swelling, vesicles, and bullae.
  • Continued exposure to the allergen may result in chronic dermatitis with lichenification and excoriation.
  • The dermatitis is itchy and may also burn and sting.
  • Dermatitis can be complicated by a secondary bacterial infection.

Fragrance allergy may affect the mouth (allergic contact stomatitis) resulting in cheilitis, gingivitis, blisters and erosions, or oral lichen planus.

Areas affected by fragrance allergy

How is fragrance allergy diagnosed?

A diagnosis of fragrance allergy will typically require a detailed patient history and is confirmed by patch testing.

  • Around 10% of those undergoing patch testing are found to have a fragrance allergy [1].
  • A positive patch test should be relevant to the products that have been in contact with the patient.
  • A weakly positive patch test can be due to irritation by the fragrance chemical rather than a true contact allergy.

Patch test diagnoses

Which allergens test for fragrance allergy?

Patch testing for fragrance allergies usually begins with a baseline series of allergens. These should include balsam of Peru, Fragrance Mix I, and Fragrance Mix II.

Balsam of Peru is extracted from the Myroxylon pereirae tree. It cross-reacts with other fragrances and a positive reaction occurs in around 50% of patients with fragrance allergy [3,5].

Fragrance Mix I can identify 75% of those with fragrance allergy when combined with balsam of Peru [1]. It is a mixture of eight fragrances:

  • Oakmoss absolute
  • Isoeugenol
  • Eugenol
  • Cinnamyl alcohol
  • Cinnamic aldehyde
  • Hydroxycitronellal
  • Geraniol
  • Amyl cinnamic aldehyde.

Fragrance Mix II increases the sensitivity to fragrance allergy. It is a mixture of six fragrances:

  • Lyral
  • Citral
  • Farnesol
  • Coumarin
  • Citronellal
  • Alpha hexyl cinnamldehyde.

Fragrance Mix II reactions

The fragrance series

A patient identified as having a fragrance allergy can be tested with the 26 individual fragrances that require labelling in the European Union [5]. A patient with a positive patch test result to one of the members of the fragrance series can avoid that fragrance by reading labels.

The 26 fragrances in the fragrance series are [6]:

  • Amyl cinnamal
  • Cinnamal
  • Cinnamyl alcohol
  • Eugenol
  • Geraniol
  • Hydroxycitronellal
  • Isoeugenol
  • Citral
  • Citronellal
  • Coumarin
  • Farnesol
  • Alpha-hexyl innamal
  • Hydroxyisohexyl 3-cyclohexene carboxaldehyde (Lyral)
  • Alpha-amycinnamyl alcohol
  • Anise alcohol
  • Benzyl alcohol
  • Benzyl benzoate
  • Benzyl cinnamate
  • Benzyl salicylate
  • Limonene
  • Butylphenyl methylpropional
  • Linalool
  • Methyl 2-octynoate
  • Alpha isomethylionone
  • Evernia furfuracea (tree moss extract) and Evernia prunastri (oakmoss extract)
  • Sorbitan sesquioleate.

It can be futile to test for fragrances that are never labelled since the patient will not be able to identify which products contain the fragrance they have reacted to.

What are the limits of patch testing?

Even if a specific fragrance chemical is identified as causing allergy, it can be difficult to avoid every product that contains it.

  • Manufacturers may not list any or all of their ingredients.
  • They can change their ingredients without giving notice to consumers.
  • The allergen may be present in low concentration, as ingredients must only be listed in a regulated product if they surpass a specified threshold concentration.

What other tests can be done?

Any leave-on product the patient suspects is causing an allergy can be applied as a customised patch for testing [3]. Patch testing is not suitable for undiluted wash-off products as they are often in stronger concentration and might irritate.

The ‘repeat open application test’ is often more practical and cost-effective than patch testing. Before using a new fragrant leave-on product, the patient should apply a dot of the product to the same area of the forearm twice a day for two weeks [3,7]. If a rash develops, the product should not be used.

What is the differential diagnosis for fragrance allergy?

The differential diagnosis for fragrance allergy may include:

What is the treatment for fragrance allergy?

Fragrance allergy is managed by identifying the allergen. It should then be avoided as best as possible. Treating the allergic contact dermatitis that results from exposure to a fragrance allergen may include:

What is the outcome for fragrance allergy?

Fragrances are ubiquitous and avoidance can be a challenge.

  • The sensitive person is likely to be allergic to several fragrances.
  • Identifying every product that contains the fragrance is virtually impossible — ingredients are frequently not listed and often have multiple names; for example, balsam of Peru has 13 names according to the Contact Dermatitis Institute [1,2].

The fragrance-sensitive patient is best to avoid products that are unlabelled or contain any fragrance.

Select products labelled ‘fragrance-free’ (so-called ‘unscented’ products could include masking fragrances) [3]. Products may still contain an unidentified fragrance, for example, if they list ‘botanical’, ‘herbal’, or ‘natural’ ingredients [3].

The fragrance-sensitive patient can use the open application test to screen any new products [3,5].

See smartphone apps to check your skin.
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Related information

 

References

  1. Book: Textbook of Dermatology. Ed Rook A, Wilkinson DS, Ebling FJB, Champion RH, Burton JL. Fourth edition. Blackwell Scientific Publications.
  2. Storrs FJ. Fragrance. Dermatitis 2007; 18: 3–7. DOI: 10.2310/6620.2007.06053. PubMed
  3. Fragrance allergy. In: Reitschel E and Fowler JF. Fisher’s Contact Dermatitis. Sixth edition. BC Decker Inc 2008, pp 393–404.
  4. Hamann CR, Hamann D, Egeberg A, Johansen JD, Silverberg J, Thyssen JP. Association between atopic dermatitis and contact sensitization: A systematic review and meta-analysis. J Am Acad Dermatol 2017; 77: 70–8. DOI: 10.1016/j.jaad.2017.02.001. PubMed
  5. Heisterberg MV, Andersen KE, Avnstorp C, Kristensen B, Kristensen O, Kaaber K, et al. Fragrance mix II in the baseline series contributes significantly to detection of fragrance allergy. Contact Dermatitis 2010, 63: 270–6. DOI: 10.1111/j.1600-0536.2010.01737.x. Journal
  6. Ung C, White J, White I, Banerjee P, McFadden J. Patch testing with the European baseline series fragrance markers: a 2016 update. Br J Dermatol 2018; 178: 776–80. DOI: 10.1111/bjd.15949. PubMed
  7. Edwards A, Blickenstaff N, Coman, G, Maibach H. Dermatotoxicologic clinical solutions: Clinical management of fragrance mix #1 #2 patients? Cutan Ocul Toxicol 2015; 34: 167–70. DOI: 10.3109/15569527.2014.926368. Journal

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