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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.
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.
Fragrance allergy is common and is believed to affect around 1% of adults . Rates in children and adolescents are around 1.8% . 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 .
Fragrances are not limited to perfumes and cosmetics. They are also found in:
Anyone who uses these products can become sensitised to them over time.
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 .
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).
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.
Typically, fragrance allergy presents as scaly erythematous plaques.
Areas affected by fragrance allergy
A diagnosis of fragrance allergy will typically require a detailed patient history and is confirmed by patch testing.
Patch test diagnoses
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 . It is a mixture of eight fragrances:
Fragrance Mix II increases the sensitivity to fragrance allergy. It is a mixture of six fragrances:
Fragrance Mix II reactions
A patient identified as having a fragrance allergy can be tested with the 26 individual fragrances that require labelling in the European Union . 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 :
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.
Even if a specific fragrance chemical is identified as causing allergy, it can be difficult to avoid every product that contains it.
Any leave-on product the patient suspects is causing an allergy can be applied as a customised patch for testing . 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.
The differential diagnosis for fragrance allergy may include:
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:
Fragrances are ubiquitous and avoidance can be a challenge.
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) . Products may still contain an unidentified fragrance, for example, if they list ‘botanical’, ‘herbal’, or ‘natural’ ingredients .
The fragrance-sensitive patient can use the open application test to screen any new products [3,5].
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