24 November 2015

EMA/HMPC/712648/2014
Committee on Herbal Medicinal Products (HMPC)

Assessment report on Myroxylon balsamum (L.) Harms

var. pereirae (Royle) Harms, balsamum
Draft

Based on Article 10a of Directive 2001/83/EC as amended (well-established use)

Based on Article 16d(1), Article 16f and Article 16h of Directive 2001/83/EC as amended (traditional
use)

Herbal substance (binomial scientific name of the Myroxylon balsamum (L.) Hams var. pereirae
plant, including plant part) (Royle) Harms, balsamum

Herbal preparation(s) Not applicable

Pharmaceutical form(s) Not applicable
Rapporteur(s) P. Claeson
Assessor(s) E. Svedlund
Peer-reviewer W. Knöss

Note: This draft assessment report is published to support the public consultation of the draft public
statement on Myroxylon balsamum (L.) Hams var. pereirae (Royle) Harms, balsamum. It is a working
document, not yet edited, and shall be further developed after the release for consultation of the public
statement. Interested parties are welcome to submit comments to the HMPC secretariat, which will be
taken into consideration but no ‘overview of comments received during the public consultation’ will be
prepared on comments that will be received on this assessment report. The publication of this draft
assessment report has been agreed to facilitate the understanding by Interested Parties of the
assessment that has been carried out so far and led to the preparation of the public statement.

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Table of contents
Table of contents ................................................................................................................... 2

1. Introduction ....................................................................................................................... 4
1.1. Description of the herbal substance(s), herbal preparation(s) or combinations thereof .. 4
1.2. Search and assessment methodology ..................................................................... 4
2. Data on medicinal use ........................................................................................................ 5
2.1. Information about products on the market .............................................................. 5
2.1.1. Information about products on the market in the EU/EEA Member States ................. 5
2.1.2. Information on products on the market outside the EU/EEA .................................... 5
2.2. Information on documented medicinal use and historical data from literature .............. 5
2.3. Overall conclusions on medicinal use ...................................................................... 6
3. Non-Clinical Data ............................................................................................................... 7
3.1. Overview of available pharmacological data regarding the herbal substance(s), herbal
preparation(s) and relevant constituents thereof ............................................................. 7
3.1.1. Primary pharmacodynamics ................................................................................ 7
3.1.2. Secondary pharmacodynamics ............................................................................ 7
3.1.3. Safety pharmacology ......................................................................................... 7
3.1.4. Pharmacodynamic interactions ............................................................................ 7
3.1.5. Conclusions ...................................................................................................... 7
3.2. Overview of available pharmacokinetic data regarding the herbal substance(s), herbal
preparation(s) and relevant constituents thereof ............................................................. 8
3.3. Overview of available toxicological data regarding the herbal substance(s)/herbal
preparation(s) and constituents thereof ......................................................................... 8
3.3.1. Single dose toxicity ............................................................................................ 8
3.3.2. Repeat dose toxicity........................................................................................... 8
3.3.3. Genotoxicity ..................................................................................................... 8
3.3.4. Carcinogenicity.................................................................................................. 8
3.3.5. Reproductive and developmental toxicity .............................................................. 8
3.3.6. Local tolerance .................................................................................................. 8
3.3.7. Other special studies .......................................................................................... 9
3.3.8. Conclusions ...................................................................................................... 9
3.4. Overall conclusions on non-clinical data .................................................................. 9
4. Clinical Data ....................................................................................................................... 9
4.1. Clinical pharmacology ........................................................................................... 9
4.1.1. Overview of pharmacodynamic data regarding the herbal substance(s)/preparation(s)
including data on relevant constituents .......................................................................... 9
4.1.2. Overview of pharmacokinetic data regarding the herbal substance(s)/preparation(s)
including data on relevant constituents .......................................................................... 9
4.2. Clinical efficacy .................................................................................................. 10
4.2.1. Dose response studies...................................................................................... 10
4.2.2. Clinical studies (case studies and clinical trials) ................................................... 10
4.3. Clinical studies in special populations (e.g. elderly and children) .............................. 10
4.4. Overall conclusions on clinical pharmacology and efficacy ........................................ 10

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5. Clinical Safety/Pharmacovigilance ................................................................................... 10
5.1. Overview of toxicological/safety data from clinical trials in humans ........................... 10
5.2. Patient exposure ................................................................................................ 10
5.3. Adverse events, serious adverse events and deaths ................................................ 11
5.4. Laboratory findings ............................................................................................. 16
5.5. Safety in special populations and situations ........................................................... 16
5.5.1. Use in children and adolescents ......................................................................... 16
5.5.2. Contraindications ............................................................................................. 16
5.5.3. Special Warnings and precautions for use ........................................................... 16
5.5.4. Drug interactions and other forms of interaction .................................................. 16
5.5.5. Fertility, pregnancy and lactation ....................................................................... 16
5.5.6. Overdose ........................................................................................................ 16
5.5.7. Effects on ability to drive or operate machinery or impairment of mental ability ...... 16
5.5.8. Safety in other special situations ....................................................................... 16
5.6. Overall conclusions on clinical safety ..................................................................... 17
6. Overall conclusions (benefit-risk assessment) ................................................................. 17

Annex .................................................................................................................................. 18
List of references ...................................................................................................... 18

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1. Introduction

1.1. Description of the herbal substance(s), herbal preparation(s) or

combinations thereof

 Herbal substance

Peru balsam is obtained from the scorched and wounded trunk of Myroxylon balsamum (L.) Harms var.
pereirae (Royle) Harms. It contains not less than 45.0-70.0 % m/m of esters, mainly benzyl benzoate
and benzyl cinnamate (European Pharmacopeia 01/2008:0754).

There is also a similar herbal substance, Tolu balsam (Balsamum tolutanum), which should not be
mixed-up with Peru balsam. Tolu balsam is the oleo-resin obtained from the trunk of the variety
Myroxylon balsamum (L.) Harms var. balsamum. In the European Pharmacopeia monograph, Tolu
balsam contains 25-50 % m/m of free or combined acids, expressed as cinnamic acid (dried drug)
(European Pharmacopeia 01/2008:1596).

 Herbal preparation(s)

Not applicable.

Constituents

The main constituents of Peru balsam (55-66 %) are esters of cinnamic and benzoic acids, especially
benzyl cinnamate (cinnamein), cinnamyl cinnamate (styracine) and benzyl benzoate. Small amounts of
vanillin and free cinnamic acid are also present (Samuelson and Bohlin, 2009)

Peru balsam contains 50-64 % of a high-boiling volatile oil called cinnamein, along with 20-28 % of
resin. The volatile oil consists mainly of benzoic and cinnamic acid esters such as benzyl benzoate,
benzyl cinnamate and cinnamyl cinnamate (styracine), with small amounts of nerolidol, free benzyl
alcohol, and free benzoic and cinnamic acids also present. In addition, traces of styrene, vanillin, and
coumarin have been identified in the material (Leung, 1996).

 Combinations of herbal substance(s) and/or herbal preparation(s) including a description of

vitamin(s) and/or mineral(s) as ingredients of traditional combination herbal medicinal products
assessed, where applicable.

Not applicable.

1.2. Search and assessment methodology

Medicinal use of Peru balsam has been documented in several handbooks that are included in the list
of references. PubMed, EMBASE and TOXNET were searched in October 2014 using the terms [Peru
balsam], [Balsam of Peru], [Peruvian balsam], [Myroxylon pereirae], and [Myroxylon balsamum],
separately. The abstracts of the references retrieved were screened manually and all articles
considered relevant were assessed and included in the list of references. TOXNET was also searched
using the terms [benzyl benzoate], [benzyl cinnamate], [cinnamyl cinnamate], [vanillin], [nerolidol],
[styrene], [farnesol] and [peruviol].

The EudraVigilance database and Vigisearch database of the World Health Organization were searched
in October 2014 using the term [Peru balsam], [Balsamum peruvianum], [Myroxylon pereirae], and
[Myroxylon balsamum].

Data was also provided by the EMA on behalf of interested parties.

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Additionally, the European Commission´s database on cosmetic ingredients (CosIng) was searched in
October 2014 for information on [Myroxylon].

2. Data on medicinal use

2.1. Information about products on the market

2.1.1. Information about products on the market in the EU/EEA Member

States

Information on medicinal products marketed in the EU/EEA

Table 1: Overview of data obtained from marketed medicinal products

Active substance Indication Pharmaceutical form Regulatory Status

Myroxylon balsamum Traditional herbal Ointment, 4.95 g/100 g Since 1944, France,
(L.) Harms var. medicinal product used Cutaneous use. TU
pereirae (Royle) for local use as For adults and
Harms, balsamum additional emollient adolescents over 12
treatment and years of age.
antipruritic for skin Apply two times daily.
disorders, as trophic Duration of use: 1 week
barrier for the
treatment of cracks,
grazes and chapping.
This overview is not exhaustive. It is provided for information only and reflects the situation at the
time when it was established.

Information on relevant combination medicinal products marketed in the EU/EEA

Not applicable.

Information on other products marketed in the EU/EEA (where relevant)

Not applicable.

2.1.2. Information on products on the market outside the EU/EEA

Not applicable.

2.2. Information on documented medicinal use and historical data from

literature

Peru balsam, included in the U.S.P. from 1820, is obtained from the tree Myroxylon pereirae. The tree
is abundant in San Salvador, but the name “Peru balsam” refers to the early import of the balsam into
Spain via the port of Lima in Peru. In the 17th century the drug appeared in German pharmacies.
Applied externally, Peru balsam has been described as an antiseptic and vulnerary, either alone, in
alcoholic solution, or in the form of an ointment. Internally it has been used as a stimulating
expectorant, but the internal use is rather rare (Claus, 1956).

Peru balsam has been described in many national pharmacopoeias, for example in the national
pharmacopoeias of Argentina, Austria, Belgium, Brazil, Chile, France, Germany, Italy, Japan, Mexico,
Netherlands and Spain. It has been reported to have a very mild antiseptic action. Diluted with equal
part of castor oil, it has been used as an application to bedsores and chronic ulcers. As an ointment
(12.5 % in simple ointment) it has been used in the treatment of eczema and pruritus. It has been

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used as an ingredient of some rectal suppositories for the symptomatic relief of haemorrhoids. Peru
balsam was formerly used as an ointment in the treatment of scabies, but it has been superseded for
this purpose by benzyl benzoate (Martindale, 1972).

Peru balsam has been used as an antiseptic dressing for wounds and as a parasiticide (Trease and
Evans, 1978).

Peru balsam has been used as a local protectant, rubefacient, parasiticide in certain skin diseases,
antiseptic, and vulnerary, and applied externally as an ointment, or in alcoholic solutions; internally,
rarely used as an expectorant (Duke, 1985).

Peru balsam has been locally used on infected and poorly healing wounds, burns, decubitus, frostbites,
prostheses pressure points, haemorrhoids. Dose: 5-20 %, but not higher than 10 % for extended
surface treatment (Hänsel, 1993).

Peru balsam has been used in topical preparations for the treatment of wounds, indolent ulcers,
scabies, diaper rash, haemorrhoids, anal pruritus, bedsores, and intertrigo (Leung, 1996).

Peru balsam has been used as a vulnerary and has been reported to be antiseptic. It is irritating when
taken orally, and has therefore only been used externally. It has been used for the treatment of burns,
frostbites, chaps, cracks, erythema, pruritus, ulcers, infected dermatitis, and other minor wounds. It
has also been used in suppositories for the symptomatic treatment of pain, pruritus, and feelings of
congestion associated with the acute attack of piles and other anal disorders. It has been an ingredient
of preparations designed to be inhaled after dispersion in hot water (Bruneton, 1999).

Table 2: Overview of historical data

Herbal Documented use /

Pharmaceutical form Reference
preparation Traditional use
Myroxylon For infected and poorly Cutaneous use Blumenthal et
balsamum (L.) healing wounds, for Preparations containing 5-20 %, for al., 1990;
Harms var. burns, decubitus ulcers, extensive surface application not Hänsel, 1993
pereirae frost bite, ulcus cruris, more than 10 %
(Royle) bruises caused by
Harms, prostheses,
balsamum haemorrhoids.

Vulnerary Applied externally, either alone, in Claus, 1956;

alcoholic solution, or in the form of an Duke, 1985
ointment
Wound balm Usual dose: 0.5-2 g daily Madaus, 1938
Eczema and pruritus Cutaneous use Martindale,
Ointment containing 12.5 % 1972 and 1993
Wound healing Cutaneous use Ljungdahl,
Diluted 1:2 in oil (e.g. ricin oil) or in 1953
5-10 % ointment
Scabies Cutaneous use Ljungdahl,
Undiluted or diluted 5-10:100 1953
vaseline or 10-15:200 spir. dilut.

2.3. Overall conclusions on medicinal use

The traditional medicinal use of Peru balsam has been documented in several medicinal handbooks
throughout a period of at least 30 years, including at least 15 years within the EU.

The strength and posology are summarised in table 3.

Table 3: Overview of evidence on period of medicinal use

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 Herbal
preparation Period of
Indication Posology, Strength
Pharmaceutical medicinal use
form
Myroxylon Traditional herbal medicinal Cutaneous use Since 1944 in
balsamum (L.) product for the symptomatic relief Adults and elderly France,
Harms var. of minor inflammations of the skin Daily dose Ljungdahl,
pereirae (Royle) and as an aid in healing of minor 5-10 % balm in semi- 1953, Claus,
Harms, balsamum wounds. solid preparations. To 1956,
be applied once daily. Martindale,
The product is a traditional herbal Duration of use: 1 week 1972,
medicinal product for use in the Blumenthal et
specified indication exclusively al., 1990,
based upon long-standing use. Hänsel, 1993

3. Non-Clinical Data

3.1. Overview of available pharmacological data regarding the herbal

substance(s), herbal preparation(s) and relevant constituents thereof

3.1.1. Primary pharmacodynamics

In agar diffusion assays, an antibacterial effect has been demonstrated in gram-positive as well as
negative strains. Also a fungicidal or fungistatic potential have been demonstrated (Hänsel, 1993). The
concentrations used were not reported.

Peru balsam has been reported to eradicate biofilms of Pseudomonas spp. (MIC 2.5 %) and
Staphylococcus aureus (MIC 2.5 %) (Kavanaugh and Ribbeck, 2012).

In radiogenic skin ulcers in rats, Peru balsam was bactericidal, accelerated the repair processes and
promoted the differentiation of scar tissue. The promotion of granulation tissue was demonstrated in
rat studies with a 5 to 15 % paraffinic solution of Peru balsam administered topically (Hänsel, 1993).

3.1.2. Secondary pharmacodynamics

No data available.

3.1.3. Safety pharmacology

No data available.

3.1.4. Pharmacodynamic interactions

No data available.

3.1.5. Conclusions

The scientific literature contains few reports on non-clinical pharmacological studies of Peru balsam.
Peru balsam has been reported to show antibacterial properties and wound healing properties in
animal studies.

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3.2. Overview of available pharmacokinetic data regarding the herbal
substance(s), herbal preparation(s) and relevant constituents thereof

No pharmacokinetic data on the herbal substance is available.

The percutaneous absorption of benzyl benzoate and benzyl alcohol was determined in vivo in
monkeys. Absorption through occluded skin was high for both compounds (approximately 70 % of the
applied dose in 24 hours). Under non-occlusive conditions, skin penetration of the substances was
reduced, presumably because of variations in the rates of evaporation from the site of application
(Bronaugh et al., 1990).

3.3. Overview of available toxicological data regarding the herbal

substance(s)/herbal preparation(s) and constituents thereof

3.3.1. Single dose toxicity

The acute oral LD50 of Peru balsam in rats was reported as >5g/kg b.w. and the acute dermal LD50 in
rabbits reported as >10 g/kg b.w. (Opdyke, 1974).

3.3.2. Repeat dose toxicity

No data available for the herbal substance.

3.3.3. Genotoxicity

No data available for the herbal substance.

3.3.4. Carcinogenicity

No data available for the herbal substance.

3.3.5. Reproductive and developmental toxicity

No data available for the herbal substance.

3.3.6. Local tolerance

Undiluted Peru balsam applied to intact or abraded rabbit skin for 24 hours under occlusion was
moderately irritating (Opdyke, 1974).

Studies conducted by Research Institute for Fragrance Materials Inc. (RIFM) (unpublished data)
showed that crude Peru balsam is a more potent sensitizer than either the oil or the absolute in the
murine local lymph node assay (Api, 2006).

Ulker et al. have studied the sensitising potential and the irritation properties of Peru balsam by
combining the local lymph node assay ex vivo (local lymph node assay-5-bromo-2'-deoxyuridine,
LLNA-BrdU) and an irritancy assay in vivo. Peru balsam, at concentrations of 0, 0.5, 5, 25, and 50 %
(w/v) in acetone: olive oil (4:1, v/v), was applied daily for 3 consecutive days to the dorsum of both
ears of female BALB/c mice. Peru balsam was reported to show a moderate sensitising potential with
an EC3 value (the estimated concentration necessary to produce a 3-fold increase in proliferation in
draining lymph nodes) of 3.09 %. The results of the irritancy assay were expressed as percentage
change in ear swelling. The reported percentage of change in ear swelling observed after exposure to a

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concentration of 5, 25 and 50 % of Peru balsam were 7 %, 15 % and 30 %, respectively (Ulker et al.,
2014).

3.3.7. Other special studies

No data available for the herbal substance.

3.3.8. Conclusions

Toxicological studies on Peru balsam are limited. Data on genotoxicity, carcinogenicity, reproductive
and developmental toxicology of Peru balsam have not been reported. In a murine local lymph node
assay, undiluted Peru balsam showed sensitising potential.

3.4. Overall conclusions on non-clinical data

The scientific literature contains few reports on non-clinical pharmacological studies of Peru balsam.
Peru balsam has been reported to exhibit antibacterial properties and wound healing properties in
animal studies.

Specific data on pharmacokinetics of the herbal substance is not available. In an in vivo study in
monkeys, the absorption of benzyl benzoate through occluded skin was high, but under non-occlusive
conditions the absorption was reduced.

Non-clinical information on the safety of Peru balsam is limited. In a murine local lymph node assay,
Peru balsam showed sensitising potential. No data on genotoxicity, carcinogenicity, reproductive and
developmental toxicology of Peru balsam have been reported. As there is no information on
reproductive and developmental toxicity, the use during pregnancy and lactation cannot be
recommended.

4. Clinical Data

4.1. Clinical pharmacology

4.1.1. Overview of pharmacodynamic data regarding the herbal

substance(s)/preparation(s) including data on relevant constituents

No data available for the herbal substance.

4.1.2. Overview of pharmacokinetic data regarding the herbal

substance(s)/preparation(s) including data on relevant constituents

Applied to healthy human skin at a concentration of 25 % in vaseline, Peru balsam was still detectable
on the skin after 1 hour using an IR spectroscopic method, but no longer after 8 hours (Hänsel, 1993).

The constituents benzyl benzoate and benzyl cinnamate are rapidly hydrolysed to benzyl alcohol, which
is oxidised to benzoic acid. Benzoic acid is conjugated in the liver with glycine to hippuric acid and
rapidly excreted via the kidneys. About 75-80 % of benzoic acid was eliminated in 6 hours in humans
after oral administration (Hänsel, 1993).

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4.2. Clinical efficacy

4.2.1. Dose response studies

No data available.

4.2.2. Clinical studies (case studies and clinical trials)

No data available.

4.3. Clinical studies in special populations (e.g. elderly and children)

No data available.

4.4. Overall conclusions on clinical pharmacology and efficacy

There are insufficient data on clinical pharmacology or efficacy available for Peru balsam to support a
well-established use indication.

5. Clinical Safety/Pharmacovigilance

5.1. Overview of toxicological/safety data from clinical trials in humans

No data available.

5.2. Patient exposure

There is no information on patient exposure to Peru balsam from clinical trials. Most information on
human exposure is from the use of Peru balsam as a food or cosmetic ingredient.

Oral use

Peru balsam is used in beverages, ices, candy, baked products and desserts and is classified by the
Council of Europe as a natural source of flavourings category 2, i.e. plants, animals and other
organisms, and parts of these or products thereof, and preparations derived from, not normally
consumed as food items, herbs or species in Europe. These source materials and preparations, on the
basis of the information available, are not considered to constitute a risk to health in the quantities
used (Council of Europe, 2000).

Peru balsam is approved for food use (Generally Recognized as Safe, GRAS) by the FDA (Leung,
1996).

A group ADI of 0-5 mg/kg b.w. for benzoic acid, the benzoate salts, benzaldehyde, benzyl acetate,
benzyl alcohol and benzyl benzoate, expressed as benzoic acid equivalent, was established by JECFA
(Joint Food and Agriculture Organization of the United Nations, FAO/WHO Expert Committee on Food
Additives) in 1996 (Tisserand and Young, 2014).

Cutaneous use

In 1982 the International Fragrance Association (IFRA) banned the use of crude Peru balsam in
fragrance and since then, the crude Peru balsam has not been used in perfumery (Api, 2006).
According to the current IFRA standard on Peru balsam crude (exudation of Myroxylon pereirae), the
recommendation is prohibited use as a fragrance ingredient due to the risk of sensitization. The IFRA

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Standards form the basis for the globally accepted and recognized risk management system for the
safe use of fragrance ingredients and are part of the IFRA Code of Practice. This is the self-regulating
system of the industry, based on risk assessments carried out by an independent Expert Panel
(webpage of IFRA http://www.ifraorg.org).

The only forms of Peru balsam used in perfumery are the extracts or distillates. Peru balsam used in
perfumery is prepared either by vacuum distillation, i.e. Peru balsam oil, or by solvent extraction, i.e.
Peru balsam absolute. The current IFRA Standard restricts the use of all extracts and distillates of Peru
balsam to a total level of 0.4 % in consumer products. This limit has been in effect since 1991 (Api,
2006). The conclusion in the standard is based on the No Expected Sensitization Induction Level
(NESIL) established by the Research Institute for Fragrance Materials (RIFM) expert panel. The NESIL
of Peru balsam extracts and distillates is 950 mikrog/cm2 (IFRA Standard on Peru balsam extracts and
distillates, 2009).

A GC-MS analysis of a sample of Peru balsam oil tested by RIFM shows that the material contains
58.2 % benzyl benzoate, 13.5 % (trans)-cinnamic acid, 12.4 % (trans+ cis)-benzyl cinnamate, 8.1 %
benzoic acid, 4.2 % (trans)-nerolidol, 1.2 % benzyl alcohol and 0.7 % (trans)-methyl cinnamate. An
estimate of the concentration of the volatiles in Peru balsam absolute is as follows: 49.5 % benzyl
benzoate, 11.5 % (trans)-cinnamic acid, 10.5 % (trans+cis)-benzyl cinnamate, 6.9 % benzoic acid,
3.6 % (trans)-nerolidol, 1.0 % benzyl alcohol and 0.6 % (trans)-methyl cinnamate. Cinnamic
aldehylde is not a constituent of Peru balsam oil or Peru balsam absolute (Api, 2006).

According to the European Commission database ‘CosIng’, which provides information on cosmetic
substances and ingredients (contained in the Cosmetics Regulation EC No 1223/2009, Cosmetics
Directive 76/768/EEC and Inventory of Cosmetic Ingredients), Peru balsam is included in Annex II, i.e.
the list of substances prohibited in cosmetic products, and should not be used as a fragrance. The
prohibition relates to the crude exudates only. Peru balsam extracts and distillates may be used as a
fragrance ingredient of cosmetic products up to a maximum concentration of 0.4 % in the finished
cosmetic product. The recommendation is based on a wide variety of test results on the sensitizing
potential of Peru balsam (SCCP/0988/06).

5.3. Adverse events, serious adverse events and deaths

Sensitisation

Hjort stated in his thesis on “Eczematous allergy to balsams. Allied perfumes and flavouring agents -
with special reference to balsam of Peru” published in 1961 that allergic reactions to Peru balsam have
been known since 1880. In the thesis, a case report of Mögling´s in 1880 is quoted as being the first
description of dermatitis from balsam of Peru. Also Lewin (1881), an American monograph by Morrow
(1887) and the French Dermatological Society by Julien (1899) are quoted and they all have described
skin reactions from Peru balsam (Hjort, 1961).

Hjort concluded in his thesis that from studies of Blumenthal and Jaffé (1933), Zündel (1936),
Engellhardt (1935) and Bonnevie (1939) it became generally appreciated that Peru balsam was a
common cause of eczema. Bonnevie, examining 1065 subjects among Danish patients with eczema,
found 5.6 % with a positive reaction to Peru balsam. In the 60’s, according to Hjort, the majority of
European dermatological clinics used routine patch test series that include Peru balsam. At that time,
the frequency of positive reactions by routine patch tests in various European clinics varied between
0.4-7 % (Hjort 1961).

In his thesis, Hjort stated that Peru balsam is obsolete from a medical point of view and its use is
limited, as its allergenic properties have been well-known in Denmark since 1939. However, Hjort

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reported that the incidence of positive reactions to Peru balsam had remained at a high level, varying
between approximately 2 and 4 % of all patients examined (in total 7500 patients). Half of the patients
who admitted contact with Peru balsam had used it for burns. Hjort anticipated that it is generally
accepted that sensitisations are particularly liable to occur during the treatment of burns (Hjort 1961).

Allergic reactions to Peru balsam and its constituents have been described in several handbooks and
scientific literature, and Peru balsam is considered a contact allergen. For example, it is stated that
Peru balsam is one of the most common contact allergens, and dermatitis as a result of contact with
the balsam has been well documented (Leung, 1996). Adverse reactions described are contact urticaria
and other skin symptoms, recurrent aphthous mouth ulcers, Quincke-Edema, broncho-obstructive and
anaphylactic reactions and vasculitis in the form of diffuse purpurea. The constituents of Peru balsam,
that are responsible for the sensitisation, are not known (Hänsel, 1993).

In the Commission E monograph, Peru balsam is contraindicated for distinct allergic dispositions.
Allergic skin reactions are described as side effects. It should not be used for more than one week
(Blumenthal, 1990). Continued application of Peru balsam to the skin may cause sensitisation
(Martindale, 1972).

In a patch test study at six Scandinavian clinics, 6.9 % of 5558 patients showed positive reactions to
Peru balsam (Magnusson et al., 1968).

Baer et al., reported the most common contact allergens of the patient population of the New York
University Skin and Cancer unit during the years 1968 to 1979. Out of 340 patients tested, 7.9 %
showed a positive reaction to Peru balsam (25 % in petrolatum) (Baer et al., 1973).

From 1995 to 1998, 2273 patients at the Dermatologisches Zentrum in Buxtehude, Germany, with
contact dermatitis were tested with the standard series (patch testing), which include Peru balsam and
445 (19.6 %) of the patients showed positive reaction to Peru balsam. The author cited that Peru
balsam is the third most common contact allergen in Switzerland, Germany and Austria (Hausen,
2001).

In the Technical Dossier on Dermal Sensitization Quantitative Risk Assessment (QRA) For Fragrance
Ingredients in 2006 (published at the IFRA webpage), it is described that the Research Institute for
Fragrance Materials (RIFM) sponsored a survey of the patch test database at the Contact Allergy Unit,
University Hospital Leuven, Belgium. In this survey a total of 3323 subjects were investigated between
2000 and 2005. Of these patients, 6.7 % were found to have a positive patch test reaction to Peru
balsam.

Between January 1990 and December 2005, 10128 patients underwent patch testing at the
Dermatology department in Leuven and 6 % reacted positively to Peru balsam (Nardelli et al., 2008).

In a report from Germany, 59 334 patients were tested for contact allergy to Peru balsam (25 % in
petrolatum) between 1996 and 2002. The result for positive reaction varied from 7.3 % to 11.5 % (see
figure 1 below) (Schnuch et al., 2004).

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Figure 1: The result for positive reactions in patients tested for contact allergy to Peru balsam (25 % in petrolatum)
in a study in Germany between 1996 and 2002 (Schnuch et al., 2004)

In the Scientific Committee on Consumer Safety (SCCS) Opinion on Fragrance allergens in cosmetic
products in 2011, numerous results from fragrance contact allergy screening have been reported. The
results for Peru balsam (25 % petrolatum) is presented in figure 2 below. Due to the high number of
positive patch test reports on Peru balsam, the SCCS considered Peru balsam to pose a high risk of
sensitisation to the consumer (SCCS/1459/11).

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Figure 2: Positive patch test reports on Peru balsam cited in the Scientific Committee on Consumer Safety Opinion
on Fragrance allergens in cosmetic products in 2011 (SCCS/1459/11)

Figure 3: Results from patch testing with Peru balsam in different population based groups cited in the Scientific
Committee on Consumer Safety Opinion on Fragrance allergens in cosmetic products in 2011 (SCCS/1459/11)

The study in Denmark, cited in the figure 3 above, is further presented in the figure 4 below.

Figure 4: The prevalence of patch test sensitivity to fragrance mix (FM) I and Myroxylon pereirae (MP) and the
frequency of self-reported dermatitis to a cosmetic product among men and women aged 18–41 years and 42–69
years in three repeated cross-sectional studies performed in the same general population in Copenhagen, Denmark
(1990, 1998 and 2006) (Thyssen et al., 2009)

Photosensitisation

In a photo patch-test, Peru balsam was able to induce photosensitisation in 0.7 and 3 % of two groups
of 1129 and 1993 patients, respectively (Hänsel, 1993).

Pharmacovigilance databases

In the EudraVigilance database for the period up to October 2014, there were no reports of suspected
adverse drug reactions associated with Peru balsam as a single active ingredient.

In the Vigisearch database of the World Health Organization’s Uppsala Monitoring Centre for the period
up to October 2014, there were several spontaneous reports of suspected adverse drug reactions
associated with the single-ingredient Myroxylon balsamum var. pereirae (rout of administration not
specified). Most of the reports are associated with allergic reactions and the highest numbers of reports

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are found for the preferred terms “dermatitis allergic” (20), “dermatitis contact” (31) and “eczema”
(41) (see table 4).

Table 4: Spontaneous reports of suspected adverse-drug reactions from the Vigisearch database of the
World Health Organization’s Uppsala Monitoring Centre

Preferred term (PT) Number of reports

Angioedema 2

Application site reaction 1

Arthritis 1

Cheilitis 1

Dermatitis 1

Dermatitis allergic 20

Dermatitis atopic 1

Dermatitis contact 31

Dermatitis bullous 3

Dyspnoea 1

Eczema 41

Erythema 1

Face oedema 1

Hypersensitivity 3

Lacrimal disorder 1

Laryngospasm 1

Photosensitivity reaction 2

Pruritus 4

Rash 3

Rash erythematous 2

Rash maculo-papular 1

Rash popular 1

Rhinitis allergic 1

Skin necrosis 1

Skin ulcer 1

Urticaria 1

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5.4. Laboratory findings

No data available.

5.5. Safety in special populations and situations

5.5.1. Use in children and adolescents

The use in children under 18 years of age has not been established due to lack of adequate data.

5.5.2. Contraindications

Hypersensitivity to Peru balsam or its constituents (esters of cinnamic and benzoic acids, especially
benzyl cinnamate, cinnamyl cinnamate and benzyl benzoate).

5.5.3. Special Warnings and precautions for use

During the treatment, intense UV-exposure of the respective skin areas should be avoided due to risk
of photosensitisation.

The use in children and adolescents under 18 years of age has not been established due to lack of
adequate data.

If the symptoms worsen during the use of the medicinal product or if signs of skin infection are
observed, a doctor or a qualified health care practitioner should be consulted.

5.5.4. Drug interactions and other forms of interaction

No data available.

5.5.5. Fertility, pregnancy and lactation

There are no data on the use of Peru balsam in medicinal products during pregnancy and lactation in
humans. The use of Peru balsam should not be recommended during pregnancy and lactation due to
insufficient data. No data on fertility is available.

5.5.6. Overdose

No data available.

5.5.7. Effects on ability to drive or operate machinery or impairment of

mental ability

No data available.

5.5.8. Safety in other special situations

No data available.

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5.6. Overall conclusions on clinical safety

There is no safety data on Peru balsam from clinical trials In the literature, Peru balsam is considered
one of the most common contact allergens and adverse reactions described in medicinal handbooks are
for example dermatitis, contact urticaria, Quincke-Edema, broncho-obstructive and anaphylactic
reactions.

Most of the reported frequencies of contact allergy to Peru balsam derive from patients patch tested for
suspected allergic contact dermatitis and cannot be related to the general population. However, as
stated in the Scientific Committee on Consumer Safety (SCCS) Opinion on Fragrance allergens in
cosmetic products, these data are useful in identifying trends and persisting problems. In patch test
studies reported in the scientific literature, prevalence figures of positive reactions to Peru balsam of
up to 19.6 % have been reported. Importantly, in studies in the general population prevalence figures
of positive reaction to Peru balsam of up to 2.6 % have been reported. Furthermore, skin sensitisation
and allergic reactions have been reported to the Vigisearch database and the highest numbers of
reports are found for the preferred terms “dermatitis allergic”, “dermatitis contact” and “eczema”.

The use of crude Peru balsam as a fragrance has been banded by the International Fragrance
Association (IFRA) since 1982. In addition, in the Cosmetics Regulation EC No 1223/2009, Cosmetics
Directive 76/768/EEC and Inventory of Cosmetic Ingredients, Peru balsam (exudate) is included in
Annex II, i.e. the list of substances prohibited in cosmetic products, and should not be used as a
fragrance. The recommendation is based on a wide variety of test results on the sensitising potential of
Peru balsam.

Due to the high risk of sensitisation it is concluded that safer medicinal products and other treatment
options are available in the proposed indication. In addition, the medicinal use of Peru balsam in EU
today is limited and crude Peru balsam is banned as fragrance in cosmetics in the EU. Therefore, the
requirement laid down in Article 16a(1)(e) of Directive 2001/83/EC that “the data on the traditional
use of the medicinal product are sufficient; in particular the product proves not to be harmful in the
specified conditions of use and the pharmacological effects or efficacy of the medicinal product are
plausible on the basis of long-standing use and experience” is not considered fulfilled.

6. Overall conclusions (benefit-risk assessment)

There is no documentation available for Peru balsam to support a well-established use indication. The
traditional medicinal use of Peru balsam has been documented in several medicinal handbooks
throughout a period of at least 30 years, including at least 15 years within the EU. However, due to the
high risk of sensitisation and since there are other treatment options available in the proposed
indication, the medicinal use of Peru balsam in EU today is limited.

In the literature, Peru balsam is considered one of the most common contact allergens and adverse
reactions described in medicinal handbooks are for example dermatitis, contact urticaria, Quincke-
Edema, broncho-obstructive and anaphylactic reactions. In patch test studies reported in the scientific
literature, prevalence figures of positive reactions to Peru balsam of up to 19.6 % have been reported.
Importantly, in studies in the general population prevalence figures of positive reaction to Peru balsam
of up to 2.6 % have been reported. Furthermore, skin sensitisation and allergic reactions have also
been reported to the Vigisearch database and the highest numbers of reports are found for the
preferred terms “dermatitis allergic”, “dermatitis contact” and “eczema”. In addition, in the Cosmetics
Regulation EC No 1223/2009, Cosmetics Directive 76/768/EEC and Inventory of Cosmetic Ingredients,
Peru balsam (exudate) is included in Annex II, i.e. the list of substances prohibited in cosmetic

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products, and should not be used as a fragrance. The recommendation is based on a wide variety of
test results on the sensitising potential of Peru balsam.

Non-clinical information on the safety of Peru balsam is limited. In a murine local lymph node assay,
Peru balsam showed sensitising potential. No data on genotoxicity, carcinogenicity, reproductive and
developmental toxicology of Peru balsam have been reported.

Based on these extensive safety concerns, the establishment of an EU herbal monograph on Myroxylon
balsamum var. pereirae (Royle) Harms, balsamum, cannot be recommended. The requirement laid
down in Article 16a(1)(e) of Directive 2001/83/EC that “the data on the traditional use of the medicinal
product are sufficient; in particular the product proves not to be harmful in the specified conditions of
use and the pharmacological effects or efficacy of the medicinal product are plausible on the basis of
long-standing use and experience” is not considered fulfilled. Safer medicinal products and other
treatment options are available in the proposed indication.

Annex

List of references

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