PLANT TALK

Contact Dermatitis to SECTION EDITOR:

Botanical Extracts THOMAS W. MCGOVERN, M.D.

David A. Kiken and David E. Cohen Ft. Wayne Dermatology, P.C.

S750 Falls Dr
Ft. Wayne, IN 46804
A review of the literature of reported cases of contact derma-
titis to a variety of natural herbal extracts is presented. Natural
extracts are commonly used ingredients in many cosmetic Some people talk to plants. Fewer people think
preparations and homeopathic remedies. Although the term plants talk to them. We want to talk about plants, and we
natural botanical extracts inherently purports to have beneficial hope that you will not only want to listen, but also,
and benign properties, these extracts can cause adverse reac- perhaps, you will even occasionally talk to us about
tions in individuals. As such, dermatologists should be cogni- plants.
zant of these agents as possible sources of allergenicity in Plants can cause an array of reactions in members of
patients presenting with contact dermatitis. Homo sapiens, and in the course of this quarterly feature,
Copyright 2002, Elsevier Science (USA). All rights reserved.
we will provide reviews and/or commentary on common
reactions to common plants, uncommon reactions to

N ATURAL BOTANICAL EXTRACTS have become

increasingly utilized in the cosmetic industry. Little,
however, is written regarding the immunogenicity associ-
uncommon plants, and many reactions in-between.
Plants and their derivatives have the potential not only
to harm the skin, but also to ameliorate skin disease,
ated with their use. With the increasing popularity of these and we welcome papers that concern either of these
items, further investigation regarding their allergenicity aspects of plants. If an occasional column is not neces-
may be necessary. sarily practical, we hope it will be enjoyable.
Approximately 40 years ago, the concept of “hypoaller-
genic” products was introduced to fill the needs of cos-
metic-intolerant patients. In the United States, cosmetic
companies are required to list the ingredients of their important that dermatologists become aware of the poten-
products to aid individuals in avoiding any particular tial adverse effects of these products.
substances that may be harmful.1 The new emphasis on
“herbal and plant” products has attracted even the most
skeptical consumer because these terms seem to have the Allergic Contact Dermatitis to Individual
connotation of having beneficial effects without the risk of Extracts
adverse side effects. Despite this great attraction to and Aloe
belief in natural ingredients, cosmetics must be regarded Aloe includes a variety of chiefly African plants of the
as a potential source of allergens. genus Aloe, having rosettes of succulent, often spiny-mar-
The incidence of the use of topical medications contain- gined leaves and long stalks bearing yellow, orange, or red
ing plant extracts is rising dramatically for the treatment tubular flowers. Aloe has been used historically for medic-
of common illnesses.1 There also are an increasing number inal purposes and has become a prevalent ingredient in
of individuals who are ingesting and applying plant sub- many cosmetic preparations because of its reported bene-
stances to their skin. Much of this increase in use can be ficial dermatologic properties. There is little literature on
attributed to popular (nutritional) literature or by word of contact dermatitis to aloe. Contact dermatitis and contact
mouth.2 Patients often neglect to include natural remedies urticaria have been described after the topical application
or cosmetics containing natural extracts during histories of aloe leaf material. Testing to 5% Aloe vera jelly for
taken for contact dermatitis evaluations. Therefore, it is delayed and immediate hypersensitivity has revealed pos-
itive reactions.2,3
From the Department of Dermatology, New York University School of Medicine, New
York, NY. Arnica Flowers
Address reprint requests to David A. Kiken, 415 East 37th Street #11D, New York, Arnica is a genus of flowers including perennial herbs in the
NY 10016.
Copyright 2002, Elsevier Science (USA). All rights reserved.
Asteraceae (Compositae) family, having opposite, simple
1046-199X/02/1303-0010$35.00/0 leaves and mostly radiate heads of yellow flowers. Arnica
doi:10.1053/ajcd.2002.34564 montana has been used for hundreds of years for sprains,

148 American Journal of Contact Dermatitis, Vol 13, No 3 (September), 2002: pp 148-152
 Contact Dermatitis to Botanical Extracts 149

bruises, painful swellings, wounds, and other injuries, as significantly diminished skin reactivity on sites treated
well as in cosmetic preparations. Numerous cases of con- with G biloba 2 days after patch removal. This study sug-
tact dermatitis caused by arnica have been reported.4 gested that G biloba carboxymethyl-␤-1,3-glucan may di-
Arnica tincture has been reported to cause bullous derma- minish allergic contact hypersensitivity reactions.
titis after treatment of a knee injury and mild skin trauma.
Both cases were confirmed by patch testing with 0.5% Lavender Oil
arnica extract in ether.5 Lavender includes a variety of aromatic Old World plants
Hausen6 tested each of the components of the Composi- of the genus Lavandula (Lamiaceae), which have clusters of
tae mix to ascertain the allergenicity of each. He reported small purplish flowers that yield oil used for its fragrance.
that 51.8% of the Compositae-positive allergic patients Two cases of contact dermatitis attributed to lavender oil
reacted to 0.5% arnica in white petrolatum. Machet et al7 have been reported.14 One was precipitated by the use of
reported a case of allergic contact dermatitis from sun- lavender oil–treated pillows resulting from a news report
flower with cross sensitivity to arnica. that touted the hypnotic benefits of lavender scent.15 In the
other, acute facial dermatitis developed in a physiothera-
Centella asiatica pist after applying a gel formulated with lavender fra-
Centella asiatica is a herbaceous plant of the Apiaceae (Um- grance. Patch testing to lavender absolute 2% pet. (Che-
belliferae) family that is purported to enhance wound motechnique, Ontario, Canada) was positive.16 Fragrances
healing by stimulating fibroblast collagen production. Con- and aromatherapy oils containing lavender have been re-
tact dermatitis to C asiatica extract has been documented ported to cause contact dermatitis.17
in numerous cases by patch testing. Vesicular dermatitis Peppermint
involving the legs, thighs, face, and trunk were reported
from the use of a cream containing C asiatica for the Peppermint oil is derived from Mentha piperita, a member of
treatment of chronic leg ulcers. Patch testing with the the Lamiaceae (Labiatae or mint) family, which has small
cream and 1% C asiatica in petrolatum both gave positive purple or white flowers and downy leaves that yield a
reactions, whereas the cream base and the standard test pungent oil. The oil is volatile and distilled with steam
series did not. Another patient with a positive patch test from the flowering plant, rectified by distillation and not
result to C asiatica extract 2% alcohol had dermatitis of the dementholized. Peppermint often is used as a flavoring
legs.8-11 agent in toothpaste, candy, gum, and mouth sprays be-
Contact dermatitis to C asiatica also has been reported cause of its cooling effect. Peppermint oil contains at least
in patients utilizing a cream version for the treatment of 45% menthol, and contact reactions to it are associated
scars and morphea. Patch testing to 1% C asiatica powder in with a burning mouth, recurrent oral ulceration, or oral
petrolatum was diagnostic.11 lichenoid reactions. Menthol, a component of peppermint
oil, may be present in toothpaste, aroma therapy, lotions,
Cucumber mouthwashes, and cigarettes. Allergic contact dermatitis
and stomatitis from menthol have been reported.18,19
Cucumber (Cucumis spp.) is a tendril-bearing, climbing or Several cases of contact dermatitis to peppermint oil
sprawling annual plant widely cultivated for its edible have been reported. A 34-year-old woman with a 9-year
cylindrical fruit that has a green rind and crisp white flesh. history of stomatitis reported worsening with mint-flavored
A 50-year-old cook was reported to have hand dermatitis foods and oral products. Patch testing results to 5% men-
that spread to his face from handling pickles. Open imme- thol in petrolatum and 1% peppermint oil in petrolatum
diate skin tests on normal skin produced positive reactions was positive. Her oral discomfort was alleviated after elim-
to cucumber.12 ination of mint from her diet and personal hygiene use.20
Chronic cheilitis, perioral contact dermatitis, oral ulcer-
Ginkgo biloba ations, and burning mouth have been reported in patients
Ginkgo biloba is a deciduous, dioecious tree native to China. who patch tested positively to peppermint oil.18,21,22
It has fan-shaped leaves and fleshy yellowish seeds with a Sources of exposure included oral antiseptic sprays, local
disagreeable odor. However, despite its cross reactivity to anesthetics, and candy.21
one of the most potent allergens, no cases of allergic Orofacial granulomatosis of the lower lip was reported
contact dermatitis to G biloba– containing products have in an individual allergic to both peppermint oil and men-
been published. This is likely because of the fact that thol. His lip swelling was reduced after elimination of
extracts of ginkgo found in cosmetic preparations do not peppermint oil and menthol from his diet.23
contain the fruit pulp, which is the only part of the ginkgo Peppermint oil also has been noted to cause contact
plant known to contain allergen. However, Castelli et al13 dermatitis in fragrances and occupational contact derma-
showed in a double-blind study that 68.2% of subjects who titis in food handlers.24,25 Patch testing results in the
had experienced allergic contact dermatitis from “various aforementioned cases typically was performed with 2%
substances in the European standard series” experienced a peppermint oil in petrolatum.
150 Kiken and Cohen

Table 1. Botanical Extract and Purported Utility

Reported Cases of
Botanical Extract Genus Name (Family) Purported Utility Contact Dermatitis

Aloe Aloe (Aloeaceae) Aid to digestion. Beneficial for complexion. Yes2,3

Angelica root Angelica (Apiaceae or Expectorant, diaphoretic, menstruation promoter, aromatic, and No
Umbelliferae) antiflatulent. Aids skin in elimination of toxins, promotes
perspiration. Digestive and circulatory tonic.
Arnica flowers Arnica (Asteraceae or Historically used for injuries and wounds and in cosmetic Yes4-7,39
Compositae) preparations. A restorative, cardiovascular tonic.
Bladderwrack Fucus (member of Antirheumatic, thyroid regulator, aid in weight reduction and obesity. No
Kingdom Protista)
Catnip Nepeta (Lamiaceae or Antiflatulent, antispasmodic, astringent, diaphoretic. No
Labiatae)
Centella asiatica Hydrocotyle (Apiaceae Enhances skin growth by stimulating fibroblasts to produce collagen Yes8-11
or Umbelliferae) fibers. Used to diminish scarring and in patients with slow-healing
wounds.
Chamomile Chamaemelum nobile Stomachic, antiseptic, antispasmodic and tonic. Expels worms. Yes29-32
(Asteraceae or Phytotherapy.
Compositae)
Comfrey leaf Symphytum Bone, blood, and tissue repair. No
(Boraginaceae)
Coriander Coriandrum (Apiaceae Improved digestion, relief of colic, relief of arthritic pain, and No
or Umbelliferae) prevention of infection.
Cucumber Cucumis Beautification. Yes37
(Cucurbitaceae)
Echinacea Echinacea (Asteraceae Immune stimulant, antiseptic, vasodilator. No
or Compositae)
Ginkgo biloba Ginkgo (Ginkgoaceae) Stimulates mental alertness. Stimulates circulation to extremities, Yes13
heart, brain, and blood. Antioxidant. Treatment of tinnitus,
vertigo, stress, senility, and asthma.
Goldenseal Hydrastis Tonic, anticatarrhal, stomachic, astringent. Used topically for insect No
(Ranunculaceae) bites, eczema, and ringworm.
Green tea Camellia (Theaceae) Anticarcinogenic with immune enhancing properties. No
Hops Humulus Sedative, nervine, analgesic, anodyne, and antiflatulent. Treatment of No
(Cannabaceae) insomnia, headaches, and anxiety.
Kelp Laminaria (member of Source of iodine. Lower rate of breast cancer, obesity, heart disease, No
Kingdom Protista) rheumatism, arthritis, high blood pressure, thyroid disease,
constipation and gastrointestinal ailments, and infectious disease.
Used for Crohn’s, colitis, ulcers, goiter, obesity and hair loss.
Lavender Lavandula (Labiatae) Antiflatulent, mild sedative, antispasmodic, antidepressant, and Yes14-17
fragrant. Treatment for headaches.
Licorice Root Glycyrrhiza (Fabaceae Gastric ulcers, hormones, hypoglycemia, adrenal support, expectorant, No
or Leguminosae) and antispasmodic.
Marigold Calendula (Asteraceae Astringent, diaphoretic, and antiinflammatory agent. Treatment of No
or Compositae) gastric ulcers.
Peppermint Mentha (Lamiaceae or Aromatic, antiflatulent, antianxiety agent, antispasmodic, antiseptic, Yes18-25
Labiatae) aids digestion, and used in treatment of migraines.
Rose hips Rosa (Rosaceae) Tonic, astringent, diuretic. Source of Vitamin C and bio-flavonoids, No
Rosemary Rosmarinus (Lamiaceae Cosmetic agent with antioxidant and antiinflammatory properties. Yes26
or Labiatae) Stomachic, aromatic, antidepressant/stimulant, antispasmodic, and
an antiseptic agent. Treatment of migraine headaches.
Sage Salvia (Lamiaceae or Gargle used to treat sore throat and laryngitis. Antiseptic, astringent, Yes27
Labiatae) expectorant, antiinflammatory, tonic, aromatic. Antihemorrhagic,
and antiflatulent. Used both internally and externally.
Saint John’s Hypericum (Clusiaceae Antidepressant and antianxiety agent. Treatment of lung diseases and Yes28
Wort or Guttiferae) urinary passage infections. Antiviral, antiinflammatory, and
astringent properties used as an aid in healing wounds.
Stinging nettles Urtica (Urticaceae) Diuretic and astringent. Source of minerals, iron, vitamins, and Yes29-32
chlorophyll used in phytotherapy.
Tea tree oil Melaleuca (Myrtaceae) Topical treatment with astringent and antiinflammatory properties Yes33-36
used for a variety of skin disorders
Witch Hazel Hamamelis Cosmetic preparations and as an astringent. Yes1,37-38
(Hamamelidaceae)

Rosemary of the Lamiaceae family were positive only to rosemary

Rosemary is an aromatic evergreen Mediterranean shrub leaf. Tests to rosemary leaf were negative in all 10 control
(Rosmarinus officinalis) that has light blue or pink flowers subjects.26
and grayish-green leaves. Belonging to the Lamiaceae fam-
ily, it is used commonly in cosmetics and herbal remedies Sage
for its antioxidant properties. Contact dermatitis was re- Sage includes a variety of plants of the genus Salvia,
ported in a 56-year-old man who used rosemary leaf plas- especially Salvia officinalis, having aromatic grayish-green,
ters to alleviate knee pain. Patch tests to various members opposite leaves, and it is used as a cooking herb. Fifty-five
 Contact Dermatitis to Botanical Extracts 151

subjects with suspected contact dermatitis were patch positively to 25% tea tree oil in soft, white paraffin, whereas
tested with a variety of common household spices. One had none reacted to d-limonene. One of 3 cases (33%) was
a positive reaction at both 25% and 10% sage in white allergic to ␣-terpinene versus 71% in Knight’s study. Nev-
petrolatum, and 2 more were positive to the 25% concen- ertheless, sesquiterpene hydrocarbons appear to be potent
tration of sage in white petrolatum.27 allergens in both studies.

St John’s Wort Witch Hazel

St John’s wort includes numerous plants of the genus Witch hazel is a deciduous shrub or small tree of the genus
Hypericum having yellow flowers and dotted leaves. It is Hamamelis, especially Hamamelis virginiana, of eastern North
traditionally gathered on St John’s eve to ward off evil. A America, having yellow flowers that bloom in late autumn
61-year-old woman chronically ingesting St John’s Wort for or winter. One hundred forty-seven of 19,000 cosmetic
depression developed erythematous itching plaques in ar- foundations filed with the Food and Drug Administration
eas exposed to natural sunlight. Photopatch testing re- in 1978 contained witch hazel.37 Periorbital dermatitis was
vealed a decrease of the MED-UVB, which was reversible reported after the use of a witch hazel– containing eye gel.
after withdrawal of the medication.28 Patch test results to Hamamelis distillate (as is and 50% in
ethanol) and cucumber extract were positive.38 Four of
Teas: Stinging Nettles and Chamomile 1,032 randomly selected normal subjects reacted to 25%
Hamamelis extract in petrolatum.1
Both stinging nettles and chamomile are used commonly
in phytotherapy. Nettles include plants of the genus Urtica No Reported Cases of Contact Dermatitis
(Family Urticaceae), having toothed leaves, unisexual
apetalous flowers, and stinging hairs that cause skin irri- Angelica root, bladderwrack, catnip, comfrey leaf, corian-
tation on contact. Chamomile is an aromatic perennial der, echinacea, golden seal, green tea, hops, kelp, licorice
herb (Chamaemelum nobile) in the Asteraceae family, native root, marigold, and rose hips all are commonly used bo-
to Europe and the Mediterranean region, having feathery tanicals used in cosmetics. A comprehensive literature
foliage and flower heads with white rays and yellow centers. search (Table 1) did not find any reported cases of contact
Chamomile tea compresses have been reported to cause dermatitis to these extracts. However, the paucity of re-
contact dermatitis or aggravate existing eczematous der- ports may be the result of difficulty testing to these sub-
matitis. Patch testing to C nobile extract has been reported stances and lack of uniform or standardized allergens.
to produce positive reactions. Gingivostomatitis was re- Further investigation with patch testing would be useful to
ported from the ingestion of a tea made from stinging verify their lack of allergenicity.
nettles. Patch testing to the leaf of common nettles (Urtica
dioica) as is produced positive reactions.29 Nettle hairs References
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