Australian bush dermatitis: compositae dermatitis in South Australia

Effects of diet on skin sensitization by nickel, poison ivy, and sesquiterpene lactones

Skin contact or exposure to sensitizers often occurs as a consequence of occupational exposures (e.g. poison ivy in forestry), wearing jewelry (e.g. nickel), or use of cosmetics (e.g. fragrances). However, many of the known skin sensitizers or their chemical variants are also consumed orally through foods or other sources. Since oral exposure to antigenic substances can lead to tolerance, consumption of sensitizers may impact the development and potency of skin sensitization, especially if the sensitizer is consumed early in life, prior to the first skin contact. To address this issue, we have reviewed human clinical and epidemiological literature relevant to this subject and evaluated whether early oral exposures to relevant sensitizers, or their chemical variants, are associated with reduced prevalence of skin sensitization to three main allergic sensitizers - nickel, urushiols of poison ivy, and sesquiterpene lactones of chrysanthemum and other plants.

Contact dermatitis as an adverse reaction to some topically used European herbal medicinal products - part 4: Solidago virgaurea-Vitis vinifera

This review focuses on contact dermatitis as an adverse effect of a selection of topically used herbal medicinal products for which the European Medicines Agency has completed an evaluation up to the end of November 2013 and for which a Community herbal monograph - now (since 2014) called a 'European Union herbal monograph' - has been produced. The present part 4 addresses species from Solidago virgaurea L. to Vitis vinifera L.

Allergenic sesquiterpene lactones from cushion bush (Leucophyta brownii Cass.): new and old sensitizers in a shrub-turned-a-pot plant

BACKGROUND

The Australian cushion bush (Leucophyta brownii) of the Compositae family of plants has become a popular pot and container plant. The plant produces the sesquiterpene lactone allergen calocephalin.

OBJECTIVES

To assess the sensitizing potential of sesquiterpene lactones from cushion bush.

PATIENTS/MATERIALS/METHODS

Eleven Compositae-sensitive patients were patch tested with seven sesquiterpene lactones isolated from cushion bush.

RESULTS

Six of seven sesquiterpene lactones elicited positive reactions in 4 of 11 patients.

CONCLUSIONS

The well-known sesquiterpene lactone pseudoivalin and its derivative pseudoivalin acetate, as well as calocephalin and tomentosin, were confirmed to be sensitizers, whereas leucophytalin A and 4α-hydroxy-5αH,10αH-1,11(13)-guaidien-8β,12-olide were shown to be allergenic for the first time. The patch test reaction patterns seem to follow the chemical patterns, which may eventually make it possible to trace primary sensitizers and advise patients more precisely.

Allergic contact dermatitis to plants: understanding the chemistry will help our diagnostic approach

Allergic contact dermatitis due to plants is common. Potentially allergenic plants and plant products are found in many everyday environments, such as the home, the garden, the workplace, and recreational settings. By improving our knowledge of allergenic plant-derived chemical compounds, we will be better positioned to identify novel allergens. We review the most relevant chemical allergens that contribute to plant allergic contact dermatitis and propose a clinical classification system based on 5 major families of chemical sensitizers: α-methylene-γ-butyrolactones, quinones, phenol derivatives, terpenes, and miscellaneous structures (disulfides, isothiocyanates, and polyacetylenic derivates). We also describe the different clinical pictures of plant allergic contact dermatitis and review currently available patch test materials. A better understanding of the specific allergens involved in plant allergic contact dermatitis will help to predict cross-reactivity between different plant species or families.

Pyrethrum Allergic Contact Dermatitis in Humans—Real?, Common?, or Not Documented?: An Evidence-Based Approach

Pyrethrum has been reported to produce allergic contact dermatitis in humans. Moreover, it has been speculated that cross reactions occur in ragweed-sensitized people. This review presents the botany, contemporary chemistry, and case reports of alleged allergic contact dermatitis. Our interpretation suggests that the evidence presented in literature does not show that allergic contact dermatitis results from exposure to pyrethrum. Similarly, the data do not suggest cross reactions in ragweed-sensitized people. Changes in the chemical composition of the refined pyrethrins suggest the putative sensitizer is present at a lower level in today's refined extracts than in ground pyrethrum flowers or the extracts used earlier.

Sesquiterpene lactone dermatitis in the young: is atopy a risk factor?

Screening for Compositae contact allergy has documented fairly high prevalence in adults, and recent studies indicate that the allergy may be more common in children than previously believed. However, detailed information on sensitization in this age group is sparse. The objective of this study was to present another 2 cases in children and review the literature. Screening with sesquiterpene lactone (SL) mix has shown prevalence of 0.5% and 1.8% in 2 studies, while screening with 2 different Compositae mixes detected 4.2% and 2.6% positives among children and adolescents. All individual case reports describe sensitization in atopic children, and the largest screening study showed a prevalence of Compositae mix sensitization that was significantly higher in children with atopic dermatitis compared with non-atopics. Compositae sensitization should be considered in children with a family or personal history of atopy, summer-related, or -exacerbated dermatitis of any kind, and a history of plant exposure. Screening with SL mix is recommended but should be supplemented with plant extracts based on exposure history. Compositae weeds, especially dandelions, seem to be important sensitizers in children.

Compositae dermatitis from airborne parthenolide

BACKGROUND

Compositae dermatitis confined to exposed skin has often been considered on clinical grounds to be airborne. Although anecdotal clinical and plant chemical reports suggest true airborne allergy, no proof has been procured. Feverfew (Tanacetum parthenium) is a European Compositae plant suspected of causing airborne contact allergy, and its most important allergen is the sesquiterpene lactone (SQL) parthenolide (PHL).

OBJECTIVES

The aims of this study were to (i) assess the allergenicity of feverfew-derived monoterpenes and sesquiterpenes and their oxidized products in feverfew-allergic patients and (ii) re-assess the role of PHL and other SQLs in airborne contact allergy.

PATIENTS AND METHODS

Feverfew-allergic patients were patch tested with extracts and fractions containing volatile monoterpenes and sesquiterpenes as well as extracts of airborne particles from flowering feverfew plants, obtained by fractionation of ether extracts, dynamic headspace and high-volume air sampler (HIVAS) technique, respectively.

RESULTS

Among 12 feverfew-allergic patients, eight had positive patch-test reactions to a HIVAS filter extract, while two tested positive to a headspace extract. Subsequent analysis of the HIVAS extract by gas chromatography and mass spectrometry detected PHL in a concentration of 510 ng mL(-1) in the HIVAS extract. Testing with a dilution series of PHL showed positive reactions down to 8.1 ng in selected patients. None of the 12 patients tested positive to monoterpenes or sesquiterpenes, whether they were oxidized or not.

CONCLUSIONS

The clinical results have proved that some feverfew-allergic patients are sensitive to airborne particles released from the plant, and isolation of PHL from the particle-containing HIVAS extract in allergenic amounts is strong evidence of PHL as the responsible allergen.

Photocontact dermatitis

Photocontact dermatitis is not a common condition, but neither is it rare. Both photo-irritant contact dermatitis (PICD) and photoallergic contact dermatitis (PACD) are seen by most dermatologists in general practice. PICD is diagnosed on clinical grounds and is usually caused by furocoumarins in plants like limes and celery. PACD is caused primarily by sunscreens but can also be the result of fragrances and antibacterial agents. PACD can only be diagnosed by photo-patch testing that most dermatologists, even those who patch test and give phototherapy in their office, do not perform. The procedure as outlined in this manuscript is relatively simple and can easily be accomplished in the dermatologist's office.

Adverse reactions associated with echinacea: the Australian experience

BACKGROUND

Fifty percent of Australians use complementary and alternative medicines (other than vitamins) in any 12-month period, of which echinacea-containing products are increasingly popular. Recent reports have highlighted the risk of allergic reactions to complementary medicines in atopic patients.

OBJECTIVE

To determine the characteristics of adverse reactions linked to use of the popular herbal remedy echinacea.

METHODS

Five privately referred patients were evaluated by the authors in their office practice via skin prick testing (SPT) on the volar aspect of the forearm and radioallergosorbent test after adverse reactions to echinacea. As there was little published information on adverse reactions to echinacea, reports to the Australian Adverse Drug Reactions Advisory Committee were reviewed. Those suggestive of possible allergic reactions were evaluated in greater detail by anonymously surveying the healthcare professionals who had reported the cases and from one unreported case. Serum was collected for further analysis where possible.

RESULTS

Five cases of adverse reactions to echinacea were personally evaluated by the authors. Two patients suffered anaphylaxis and a third had an acute asthma attack 10 minutes after their first ever dose of echinacea. The fourth patient suffered recurrent episodes of mild asthma each time echinacea was ingested, and the fifth developed a maculopapular rash within 2 days of ingestion which recurred when rechallenged. Three of the patients had positive SPT results. Three reported repeated spontaneous "challenges" and symptoms after further ingestion of echinacea. Fifty-one Australian adverse drug reports implicating echinacea were also reviewed. There were 26 cases suggestive of possible immunoglobulin E-mediated hypersensitivity (4 anaphylaxis, 12 acute asthma, 10 urticaria/angioedema). Of these 26 patients, age ranged from 2 to 58 years, 78% were female and >50% were known to be atopic. Four were hospitalized, 4 reacted after their first known exposure, and 1 patient suffered multiple progressive systemic reactions. Twenty percent of 100 atopic subjects who had never taken echinacea also had positive SPT results to this substance when tested by one of the authors in his office practice.

CONCLUSION

Some atopic subjects have positive SPT results to echinacea in the absence of known exposure. Atopic subjects are also overrepresented in those experiencing reactions to echinacea. The possibility that cross-reactivity between echinacea and other environmental allergens may trigger allergic reactions in "echinacea-naïve" subjects is supported by the Australian data. Given its widespread (and largely unsupervised) community use, even rare adverse events become inevitable. Atopic patients should be cautioned appropriately.

Compositae dermatitis

Compositae dermatitis is an allergic contact dermatitis. The most important allergens in the Compositae family are sesquiterpene lactones (SL), which are present in the oleoresin fraction of leaf, stem, flower and possibly pollen. Compositae dermatitis is most frequently seen in middle-aged and elderly people in patterns reflecting airborne or direct contact with the allergens. The pattern typically starts in summer and disappears in the autumn or winter. Repeated exposure over many years may lead to a chronic and, at times, a disseminated pattern. Seasonal variation does not occur in occupational Compositae dermatitis. In addition to the classically described airborne pattern of face, 'V' of neck, hands and forearms, hand dermatitis is now recognized to be an equally common presentation. This variability of clinical features, and the frequent occurrence of atopic dermatitis and contact allergy to one or more compounds, highlights the need for routine patch testing with sesquiterpene lactone mix 0.1% (Thermal, Hamburg, Germany), combined with aimed patch testing with Compositae plants and extracts. Avoidance of the plants and plant extracts of this large family can be difficult due to its widespread occurrence in flower, herb and vegetable gardens, urban and rural weed population and native vegetation. Importantly, Compositae plant extracts are present in many cosmetics, shampoos, herbal creams and ingested herbal remedies and tonics.

Allergic contact dermatitis to multiple sawdust allergens

A 73-year-old man presented with an 8-year history of a dermatitis affecting his face, dorsum of hands, and forearms. He was a retired cabinet maker but still carried out some timber work at home. He was patch tested and found to be positive to colophony and saw-dust samples from four different timbers: Silky Oak, Queensland Hoop Pine, Radiata Pine and Australian red cedar.

Compositae dermatitis: a survey

Compositae dermatitis in an allergic contact dermatitis, frequently chronic, triggered by plants of the Compositae family. The condition, which is seen, in particular, in middle-aged and elderly persons, typically starts in the summer months with an acute eczema either corresponding to areas exposed to light and air, or corresponding to areas of plant contact; it disappears spontaneously during the fall of the year. Repeated exposure over a number of years may cause severe intractable dermatitis affecting the patient throughout the year. The responsible allergens are sesquiterpene lactones, and investigations to date indicate that the frequency of the allergy is similar to that seen with some of the contact allergens of the standard patch test series. The diagnosis, however, is difficult, partly due to the fact that the clinical picture may be mistaken for a photodermatosis, and partly owing to the difficulty in obtaining commercially available allergens for patch testing. The diagnosis is therefore based on testing with plant extracts, which can cause pronounced local reactions and possibly active sensitization. A survey is given of the possible modes of sensitization, sex and age distribution, the relationship to photosensitivity and atopy, as well as the possible treatment. It is concluded, on the basis of the chronic nature of the disease, and the diagnostic and treatment problems, that continued intensive research into the condition is urgently needed.

Dandelion dermatitis

7 subjects, each giving a history suggesting dandelion dermatitis, were patch tested with extracts of dandelion as well as with other common members of the Compositae and to the sesquiterpene-lactone-mix. All were positive to dandelion extracts but only 2 reacted to the sesquiterpene-lactone-mix. Although the mix is a useful screening test for chrysanthemum dermatitis, it may miss dandelion allergy.

Airborne contact dermatitis from Compositae plants in northern India

60 patients (45 male and 15 female) with suspected airborne contact dermatitis from Compositae (Asteraceae) plants and 20 age-matched controls (15 male and 5 female) were investigated. Patch tests were performed with ethanolic plant extracts of 4 Compositae plants, Parthenium hysterophorus, Chrysanthemum morifolium, Dahlia pinnata and Tagetes indica, all prevalent in northern India. 55 (92%) patients showed positive patch tests, with 35 (64%) demonstrating positive tests to extracts of only 1 of the 4 plants tested. No positive patch tests were seen in the controls. Parthenium hysterophorus (78%) was the most frequent plant reacting, followed by Chrysanthemum morifolium (42%), Dahlia pinnata (18%) and Tagetes indica (7%).

The sensitizing capacity of Compositae plants. VI. Guinea pig sensitization experiments with ornamental plants and weeds using different methods

Experimental studies in guinea pigs using ether extracts of 20 different species of the Compositae plant family were carried out with the open epicutaneous method (OET) and the guinea pig maximization test (GPMT). The results demonstrate that Cnicus benedictus (blessed thistle), Chrysanthemum leucanthemum (marguerite, ox-eye daisy) and Helianthus debilis (dwarf sunflower) are strong sensitizers while Helenium amarum (bitterweed), Gaillardia amblyodon (blanket flower), Artemisia ludoviciana (prairie sage), Ambrosia trifida (giant ragweed) and Solidago virgaurea (goldenrod) are medium sensitizers. Twelfe species revealed only a weak or no sensitizing capacity; among those were corn flower, wormwood, mugwort, coltsfoot and dandelion. Cross-reactivities were observed in a considerable number of the investigated plant species. The sensitizing power as well as the observed cross-reactions depend on the occurrence of sesquiterpene lactones which have an alpha-methylene group exocyclic to the lactone in common ("immunologic requisite"). As a practical consequence, patients suffering from allergic contact dermatitis due to Compositae species are strictly requested to avoid contact with the offending species and all related species to prevent recurrences of their skin lesions.

Bindii (Jo Jo) dermatitis (Soliva pterosperma [Compositae])

Bindii dermatitis is a distinctive eruption occurring in some Australian children during spring and early summer and characterized by discrete erythematous papules with puncta, concentrated over the palms, soles, and knees. In three affected individuals (but not in thirteen controls), pricking the skin with bindii seed produced an erythematous, indurated papule that appeared within 48 hours of intradermal pricking and simulated the primary lesion. Pathogenesis may involve an allergic reaction with a retained depot of antigen rather than a nonspecific foreign body injury reaction.

Persistent light reactions. A review with opinions

A review of persistent light reactions in South Australia is related to the European, American and Australian experience of photosensitivity and compositae dermatitis. It is argued that contact and drug photosensitising chemicals are retained in the dermis and slowly metabolised, and that actinic reticuloid will clear if all potential photosensitisers are avoided.

The spread of Composite (Compositae) weeds in Australia

Many Composite weeds, vegetables and ornamental plants have been introduced to Australia since European settlement began in 1788. The present distribution of 4 weeds known to cause contact dermatitis is recorded on maps, and a short history of each is given. The relatively slow spread of these weeds is contrasted with the rapid spread of Parthenium hysterophorus which caused epidemic contact dermatitis in India and which has recently caused dermatitis in Northern Australia. Australian native Composite plants may play some part in the perpetuation of contact dermatitis initiated by weeds introduced into Australia.

Plant dermatitis due to the Compositae (Asteraceae) family

Dermatitis due to members of the Compositae (Asteraceae) family of plants has been reported for many years from several parts of the world. Nevertheless, it seems to be overlooked by many present-day clinicians, undoubtedly because clinically it mimics photodermatitis or an airborne contact dermatitis of nonplant origin. This clinical review summarizes the rich literature on the subject, emphasizes the remarkably consistent clinical picture, and updates for readers relevant advances in botanical biochemistry and clinical implications, as well as current methods for diagnosis, attempts at treatment, and concepts of pathogenesis. It is hoped that the review will focus needed attention on this syndrome and will enhance prospects for accurate diagnosis, as well as further investigations into treatment and prevention.

Airborne contact dermatitis from Compsoitae oleoresins simulating photodermatitis

American ragweed (Ambrosia) dermatitis has an airborne pattern and is caused by lipid soluble oleoresins of pollens. A similar weed dermatitis has been described in India and Australia. The weeds involved were all of the Compositae family and contain sesquiterpene lactones with one common antigenic determinant. This study reports seven Danish patients treated for many years under the diagnosis of photodermatitis, who eventually proved to suffer from Compsoitae oleoresin dermatitis. Probably, Compsitae dermatitis is a world-wide disease, although aften misdiagnosed as has happened in Scandinavia.

Contact dermatitis from radiata pine

Sawdust from radiata pine trees which are grown extensively throughout South Australia causes various forms of contact dermatitis. The various forms are described in nine cases which illustrate that the early diagnosis of industrial dermatitis is necessary to prevent the condition from becoming chronic. A chance association between colophony in radiata pine sawdust and colophony in adhesive plaster, which caused contact dermatitis when used in patch testing, led to the discovery of these cases.

Compositae sensitivity among patients with contact dermatitis: value of compositae oleoresins in a standard test series

Patch tests with 24 Compositae species were performed on 81 patients suspected of having a plant dermatitis, of whom 16 had positive reactions to various species. When Compositae were included in the standard series, 10 of 488 consecutive patients (2%) were found to be sensitive to one or more species. Most of the positive test reactions were relevant. Fourteen of 16 sensitivities could have been detected by testing with two mixtures of Compositae. Alantolactone could not serve as a screening agent, since four of seven Compositae-sensitive patients had negative reactions to it. Concomitant reactions to balsams were found in four of 10 patients with unexpected sensitivy to Compositae. The clinical pattern of Compositae dermatitis may be that of a lichenified photo dermatitis. These cases are invariably missed, unless patch tests with Compositae are performed. Another group of patients have hadn eczema and also require patch tests with Compositae for etiological diagnosis. Because positive, relevant reactions are common, inclusion of a safe and reliable Compositae screening test in the standard series is urgently required. At the present stage, however, our test materials are sometimes irritant and they have occassionally caused active sensitization.