For individuals diagnosed with a Balsam of Peru (BofP) allergy through patch testing, managing the condition often involves more than just avoiding topical allergens. A BofP avoidance diet can be a valuable tool in minimizing reactions and improving skin conditions. This article delves into the connection between BofP allergy and diet, providing a comprehensive guide to navigating a BofP avoidance diet.
What is Balsam of Peru?
Balsam of Peru is a sticky, aromatic substance derived from the Myroxolon balsamum tree, native to El Salvador. Despite its name, the "Peru" part originates from El Salvador being part of a Peruvian colony when it was first named. It has a scent reminiscent of vanilla and cinnamon due to its composition, which includes 60-70% cinnamein (a combination of cinnamic acid, cinnamyl cinnamate, benzyl benzoate, benzoic acid, and vanillin). The remaining 30-40% consists of resins of unknown composition and essential oils similar to those found in citrus fruit peel.
Balsam of Peru is used in various products for its aromatic, fixative, antiseptic, antifungal, and antiparasitic properties. Its main applications include:
- Fragrance in perfumes and toiletries
- Flavoring in food and drink
- Healing properties in medicinal products
Examples of products that may contain Balsam of Peru include:
- Perfumes and cosmetics
- Flavorings and spices
- Haemorrhoidal suppositories and ointments
Balsam of Peru Allergy: A Type IV Hypersensitivity
Balsam of Peru allergy is not a typical food allergy that causes anaphylactic shock. Instead, it is a Type IV Delayed Hypersensitivity allergy mediated by the body’s T-cells. This means that reactions are not immediate and can take hours or days to manifest.
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Typical allergic contact dermatitis reactions may occur in individuals allergic to Balsam of Peru or any other chemically related substances. A flare-up of hand eczema is common in sensitive individuals if they use or consume products containing Balsam of Peru or related allergens. Sensitivity to a perfume or cream is usually the first indicator of an allergy to Balsam of Peru. Patch testing using 25% Balsam of Peru in petrolatum is used to confirm this. A positive result to Balsam of Peru is seen in 50% of fragrance allergy cases.
The Rationale Behind a Balsam of Peru Avoidance Diet
Many BofP chemical constituents, such as cinnamates, vanillin, benzoic acid, and eugenol, are found in various foods. Common culprits include citrus fruits, tomatoes, spices, condiments, sweets, and liquor. For individuals allergic to BofP, eliminating topical allergens may not be sufficient to remain reaction-free.
The concept can be visualized as a bucket. When the bucket is full (representing the body's tolerance level), any additional exposure, even accidental, will cause it to overflow, leading to a reaction. A BofP avoidance diet aims to "empty" the bucket, reducing the overall allergen load and making the body less susceptible to reactions from accidental exposures.
Identifying and Avoiding Foods High in Balsam of Peru Constituents
A BofP avoidance diet involves excluding foods that contain BofP constituents like cinnamates, vanillin, benzoic acid, and eugenol. It is important to use only ingredient-labelled products that do not list Balsam of Peru or any of its other names on the label.
Here's a breakdown of food categories to be mindful of:
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- Citrus Fruits: Oranges, lemons, grapefruits, as well as juices, marmalades, & baked goods containing citrus.
- Spices: Cinnamon, cloves, vanilla, allspice, anise, ginger, turmeric
- Flavorings: Foods that may contain cinnamon and vanilla flavorings, such as ice cream, baked goods, candy, and chewing gum. Flavor is also found in toothpaste, chewing gum, mints, cough drops, and mouthwash, in addition to other foods.
- Tomatoes: Tomatoes and tomato-containing products.
- Red Sauces: Red sauces and tomato-based foods, including salsa, pizza, chili, and Italian food.
- Spicy Condiments: Ketchup, chili sauce, barbecue sauce, and chutney.
- Chocolate: Cacao beans are high in benzoates and eugenol, and prepared chocolate can contain additions like soy lecithin and vanilla/vanillin.
- Cola: Specifically Coca-Cola, Dr. Pepper and Pepsi.
- Aperitifs: Certain alcoholic beverages.
Implementing a Balsam of Peru Avoidance Diet
- Consult with a Healthcare Professional: Before starting any elimination diet, consult with a doctor or registered dietitian. They can help determine if a BofP avoidance diet is appropriate and provide guidance on ensuring nutritional adequacy. Alert your doctor or dentist to the fact that you have an allergy to Balsam of Peru.
- Read Labels Carefully: Meticulously examine food labels for any of the listed ingredients or hidden sources of BofP.
- Plan Meals: Prepare meals in advance to avoid accidental consumption of restricted foods.
- Consider a Smoothie: A BofP avoidance diet smoothie can be a helpful way to supplement nutrients while recovering from an exposure.
- Be Patient: It takes time to see results. Stick with the diet consistently for at least 8-10 weeks to allow the body to clear out the allergens.
Reintroducing Foods and Identifying Triggers
After 8-10 weeks of clearance, gradually reintroduce one food back into the diet each week. This will help identify specific foods that trigger reactions. Keep a food diary to track any symptoms that arise after reintroducing a particular food.
It’s important to remember that not everyone reacts to every food on the BofP list. The goal is to identify and avoid individual trigger foods, rather than unnecessarily restricting the entire diet.
Self-Testing Products for Balsam of Peru
Self-testing a product for Balsam of Peru is possible but should be done only after first talking with your doctor. This should be done only with products that are designed to stay on the skin such as cosmetics and lotions. Apply a small amount (50 cent sized area) of the product to a small tender area of skin such as the bend of your arm or neck for 5 days in a row. Examine the area each day and if no reaction occurs, you are unlikely to be allergic to it. However, it may still cause an irritant reaction, so be cautious.
Dietary Factors and Dermatitis: Atopic Dermatitis and Systemic Contact Dermatitis
Given increasing awareness of the link between diet and health, many patients are concerned that dietary factors may trigger dermatitis. Research has found that dietary factors can indeed exacerbate atopic dermatitis or cause dermatitis due to systemic contact dermatitis.
In atopic dermatitis, dietary factors are more likely to cause an exacerbation among infants or children with moderate-to-severe atopic dermatitis relative to other populations. Foods may trigger rapid, immunoglobulin E-mediated hypersensitivity reactions or may lead to late eczematous reactions. While immediate reactions occur within minutes to hours of food exposure, late eczematous reactions may occur anywhere from hours to two days later.
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Screening methods, such as food allergen-specific serum immunoglobulin E tests or skin prick tests, can identify sensitization to specific foods, but a diagnosis of food allergy requires specific signs and symptoms that occur reproducibly upon food exposure. Many patients who are sensitized will not develop clinical findings upon food exposure; therefore, these tests may result in false-positive tests for food allergy. This is why the gold standard for diagnosis remains the double-blind, placebo-controlled food challenge.
In another condition, systemic contact dermatitis, ingestion of a specific food can actually cause dermatitis. Systemic contact dermatitis is a distinct T-cell mediated immunological reaction in which dietary exposure to specific allergens results in dermatitis. Balsam of Peru and nickel are well-known causes of systemic contact dermatitis, and reports have implicated multiple other allergens.
Understanding Atopic Dermatitis and Food Allergies
The subject of diet and dermatitis has been studied for decades. Many patients with chronic dermatitis, and many parents of children with atopic dermatitis (AD), are concerned about whether diet can either cause or exacerbate dermatitis. A number of studies have been performed to investigate the link between diet and dermatitis. Research has established that for some patients with AD, specific foods can indeed lead to an exacerbation of dermatitis. In the case of systemic contact dermatitis (SCD), specific foods can actually cause dermatitis.
Atopic dermatitis is a chronic, relapsing, inflammatory skin condition that causes erythematous, pruritic skin lesions. While estimates vary, particularly according to geographic region, it has an estimated lifetime prevalence in children of 10 to 20 percent, and a prevalence in adults of 1 to 3 percent. A rising prevalence over the last several decades has been noted in particular in industrialized countries. While the development of AD has clearly been shown to be multifactorial, one area of research has focused on food allergies as an exacerbating factor.
It is well known that AD and food allergy are highly correlated. The overall estimated prevalence of food allergy in children with AD has ranged widely, from 20 to 80 percent, due to different populations, AD severity, and defining criteria for food allergy. While AD and food allergy are clearly correlated, the subject of food allergens serving as an exacerbating factor for AD has historically been a subject of controversy. Clinical studies over the last several decades, though, have confirmed that food allergy may play a role in exacerbating AD in some patients. Those most likely to be impacted are infants and children with moderate-to-severe AD. The proportion of AD patients whose skin symptoms are linked to food allergens has varied considerably in different studies.
The majority of food allergic reactions in the United States are triggered by peanuts, tree nuts, cow’s milk, eggs, soy, wheat, seafood, and shellfish.
Diagnosing Food Allergies: Sensitization vs. Allergy
The term “food allergy” is frequently used by patients as well as the media. Due to the confusion surrounding food allergy, an expert panel was convened to publish clinical guidelines for the diagnosis and management of food allergy. The panel, in reviewing the literature, noted that “multiple studies demonstrate that 50 to 90 percent of presumed food allergies are not allergies.” History, therefore, is often not a reliable indicator.
Much of the confusion surrounding testing for food allergy is related to the concept of sensitization. The panel stated that sensitization is evidenced by allergen-specific IgE. However, patients can have sensitization without ever developing clinical symptoms upon exposure to these foods. Therefore, a diagnosis of IgE-mediated food allergy requires both sensitization and specific signs and symptoms following food exposure.
Immediate reactions are IgE-mediated and may include a wide spectrum of clinical findings. These may occur within minutes to hours of food ingestion and can present as a single symptom or a combination of symptoms. These reactions may involve a single organ system or multiple systems, including the cutaneous, respiratory, cardiovascular, and gastrointestinal systems. While immediate reactions can manifest as anaphylaxis, which is a rapid-onset, severe, and potentially fatal reaction, reactions may also vary widely in severity.
It has long been recognized that immediate reactions can lead to an exacerbation of AD due to pruritus and the resultant scratching.
Late Eczematous Reactions
Late eczematous reactions may occur anywhere from hours to two days following ingestion of a trigger food. Unlike an immediate reaction, the onset of late eczematous reactions is delayed. Following ingestion of a food, affected persons experience an exacerbation of AD. The overall prevalence of late eczematous reactions is unknown, but is likely underestimated, as studies of food allergy do not always evaluate for this type of reaction.
The pathogenesis of late eczematous reactions remains unknown. While late eczematous reactions are broadly categorized as non-IgE-mediated, the pathophysiology is unclear. Due to this fact, no accurate laboratory testing is available at this time. While studies of DBPCFCs have confirmed that some patients exhibit food allergen-specific IgE on testing, the positive predictive value (PPV) is low. T cells do play a role, as food allergen-specific T cells have been shown to be involved in late eczematous responses to food.
Diagnostic Approaches for Food Allergies
While testing for food allergies is not warranted in all children with a new diagnosis of AD, it may be helpful in a specific subset of patients. The NIAID expert panel suggests that children less than five years of age with moderate-to-severe AD should be evaluated for a food allergy if they have intractable AD despite optimal management and topical treatment. If suspecting an immediate reaction, testing may include SPT and allergen-specific serum IgE tests. However, as stated earlier, these test for sensitization only. In cases of suspected late eczematous reactions, no accurate laboratory testing is available at this time, as the pathophysiology is unclear. Therefore, DBPCFCs remain the gold standard in diagnosis, with an observation period that extends to two full days. Some researchers have also recommended a diagnostic elimination diet, in which a suspected food (based on history) is excluded for a period of 4 to 6 weeks.
In cases of confirmed food allergy, patients would expect that avoidance of that food would help with their dermatitis. Studies have confirmed this, in both IgE-mediated reactions and late eczematous reactions.
Considerations for Food Elimination Diets
While food elimination diets may be helpful in a subset of patients with AD, they must be recommended with caution, and only in specific cases. Food elimination diets should not be recommended to all patients with AD. The effects of food restriction diets are difficult to quantify due to the multifactorial nature of AD development, the challenges inherent in compliance to diet, the need for patient education, and the shift to alternative foods that may have increased or decreased nutrients.
In summary, food elimination diets may be helpful in a subset of patients with AD, but they must be recommended with caution and only in specific cases. The NIAID expert panel recommends avoidance of the specific food allergens in cases of documented food allergies concurrent with AD. In the absence of documented food allergies, dietary restrictions are not advised for patients with AD, as no evidence exists to suggest reduction of symptom severity.
Even among those for whom there is proven benefit, care must be taken with food avoidance. Indiscriminate restriction of potentially allergenic foods may adversely affect growth and development and lead to nutritional deficiencies. Food allergies among children tend to diminish with age, with the exception of nuts. Most children with food allergies eventually tolerate milk, egg, soy, and wheat, while allergy to peanuts and tree nuts is likely to persist. Thus, after 12 to 24 months, restricted foods may be reconsidered for inclusion in the diet.
Systemic Contact Dermatitis (SCD) and Dietary Allergens
In persons with systemic contact dermatitis (SCD) due to dietary allergens, ingestion of specific foods can cause dermatitis. SCD is a specific immunological reaction, mediated by T cells, in which dermatitis occurs following systemic exposure to an allergen. The reaction requires sensitization to an allergen with subsequent systemic exposure. This exposure may occur via several routes, including ingestion, inhalation, intravenous administration, or intramuscular administration. Our focus is on dietary exposure to allergens. Research indicates that in a subset of patients with allergic contact dermatitis (ACD) to specific allergens, dietary elimination of these allergens will result in improvement of their dermatitis. Well-described allergens in foods that can trigger SCD include balsam of Peru (BOP) and nickel.
ACD and SCD are related but have distinct immunological reactions. A subset of patients with ACD to a specific allergen will develop SCD following systemic exposure. Both reactions are T-cell mediated, and patch testing is used in both conditions to identify the causative allergens. Clinical presentation, however, may differ markedly. ACD occurs due to external allergen exposure that results in a local inflammatory response at the site of skin contact.
SCD may have multiple clinical presentations. Some patients present with localized flares of dermatitis at sites of previous involvement, while others present with a non-specific exacerbation of their dermatitis. SCD due to ingestion of BOP may result in either localized dermatitis, such as of the face, hands, or genitals, or a widespread dermatitis. Nickel SCD often presents with acute vesicular hand dermatitis, while several allergens have resulted in a maculopapular rash. SCD may result from a number of oral medications, and may result in a specific cutaneous reaction pattern known as SDRIFE (symmetrical drug-related intertriginous and flexural exanthema). This pattern was originally known as baboon syndrome, due to the symmetric erythematous eruption of the buttocks and flexural areas.
While both ACD and SCD are mediated by T cells, the pathogenesis of SCD is not well-understood. A key question is why only a subset of patients… "I know I'm allergic to lotions with fragrance. This may sound surprising, but it's entirely possible. While some may wrongly blame food and diet for their skin problems, there are some situations in which testing can be recommended. These situations also include cases of suspected systemic contact dermatitis (SCD), a specific type of allergy triggered by food. SCD traditionally refers to a skin condition where an individual who is cutaneously sensitized to an allergen will subsequently react to that same allergen or a cross reacting allergen via a different route, such as through consumption of foods containing the allergen. This is in contrast to allergic contact dermatitis (ACD), where an allergic reaction forms as a result of the substance touching the skin.
Fragrance Allergies and Balsam of Peru
Conversely, SCD may be caused by an all-natural substance referred to as balsam of Peru (BOP). If your dermatologist suspects that you're allergic to skin care products or other external exposures, they'll recommend patch testing. Studies have found that among patients undergoing patch testing, fragrance additives are one of the most common allergens. If there are positive results indicating sensitivity to certain fragrances, they may recommend complete avoidance of fragrance additives in skin care products. This is easier said than done, since a product labeled “fragrance-free” may still contain fragrance additives due to marketing regulations.
In a study by Salam et al., patients with chronic dermatitis and an allergy to fragrance additives underwent diagnostic patch testing for balsam of Peru (BOP), fragrance mix (FM), cinnamic aldehyde, and Tolu balsam. Table 1. They found that after six weeks of following the diet, of the 45 patients studied, close to half had complete or significant improvement in their dermatitis.
Key Foods to Avoid on a Balsam of Peru Diet
There are a number of different foods and beverages that should be avoided while on the BOP diet. The main culprits are any foods containing tomatoes, citrus, and cinnamon. In the clinical context, many patients with BOP allergy report allergic reactions after consuming tomatoes, particularly tomato sauce found in pizza or spaghetti. Other instances are when cinnamon is consumed sprinkled on coffee, oatmeal, or in baked goods. Vanilla and cloves can also be found in baked goods and have to be monitored when on the BOP diet. Citrus fruits, such as lemons, oranges, or those in juices are another frequent trigger.
Recovering from Systemic Contact Dermatitis
Recovering from SCD can be a slow process, as is the case in recovering from exposure to any allergy-causing substances. It is recommended that the BOP elimination diet be followed for at least six weeks, after which foods can be re-introduced slowly and one at a time. Every few days, a food is re-added and the symptoms are monitored to see if they are able to pinpoint particular trigger foods. The slow nature of the process is partially due to the slow onset of flare up after consuming the triggering food. For example, if one is allergic to cinnamon, one does not get an immediate flare up and experience burning of the skin right away. It may take a few hours to days for the dermatitis to manifest.
Importance of Individualized Approach
It is also important to note that most do not react to every food on the BOP list. Patients allergic to fragrance additives or balsam of Peru on patch testing can discuss with their dermatologist whether or not the BOP avoidance diet is right for them.
Managing Dermatitis: Treatment Options
Once dermatitis appears on the skin, treatment is as for any acute dermatitis/eczema. If you have an allergy to Balsam of Peru, try to identify possible sources of contact and avoid them.