Sunscreen allergy due to cinnamyl alcohol in a ketoprofen-sensitized patient

ARTICLE

ejd.2011.1256

Auteur(s) : Caterina FOTI c.foti@dermatologia.uniba.it, Paolo ROMITA, Annarita ANTELMI

Unit of Dermatology - Department of Internal Medicine, Immunology and Infectious Diseases, University of Bari, Policlinico, Piazza Giulio Cesare, 11, I-70124 Bari, Italy

Allergic contact dermatitis (ACD) and photoallergic contact dermatitis (PACD) to sunscreens are frequently observed in ketoprofen (KP)-sensitive patients, probably because they widely use these products to protect themselves from prolonged photosensitivity [1]. These allergic reactions are often due to UV filters [2, 3], but our case shows that fragrances can also be the culprit allergens.

A 38-year-old, non-atopic, skin type III man presented with a severe generalized rash which occurred after the application, for three consecutive days, of Nivea Sun Kids 30+ SPF sunscreen (Beiersdorf, Milano, Italia) to all exposed areas before sunbathing. By the following day, the reaction worsened. The rash resolved in 2 weeks with once daily topical application of mometasone furoate (Elocon^®, Schering-Plough SpA, Milan, Italy). The history revealed episodes of ACD to corticosteroids and photo-contact reactions to topical drugs containing KP. The patient had never previously complained of sunscreen allergy. Three months after the resolution of the dermatitis, the patient was patch tested with the baseline SIDAPA (Italian Society of Allergological, Occupational and Environmental Dermatology) standard series (Firma^®, Florence, Italy) and with the eight ingredients of Fragrance Mix (FM)-1 (Firma, each at 2% in pet., except for cinnamaldehyde tested at 1% in pet.). Patch tests were applied on the back and left in occlusion for 2 days using Finn Chambers^® (Ø 8 mm; SmartPractice, Phoenix, USA) technique on Scanpor^® tape (Norgesplaster A/S, Vennesla, Norway) and readings were made at 48 h and 96 h (D2 and D4). Patch test and photopatch tests were also performed with the SIDAPA photopatch test series and with the Nivea Sun Kids 30+ SPF sunscreen and all its ingredients. Tests were carried out by applying the allergens on one side of the back, taking the Scanpor tape off at 24 h and exposing them to UVA rays at the dose of 5 J/cm² (UV 801 KL, PUVA/TL01, Photochemotherapy, Herbert Waldman, Werk für Lichttechnik, Germany), whereas the opposite side of the back was covered with a black cloth. Test reactions were read at 1 and 3 days after irradiation (D2 and D4). The reactions were classified according to International Contact Dermatitis Research Group (ICDRG) guidelines. Patch tests gave positive results to fragrance mix-1 (++), corticosteroids mix (21-hydrocortisone acetate 1%, budesonide 0.01%, hydrocortisone 17-butyrate 1%) (++), Myroxylon pereira (++), Nivea sun kids SPF 30+ (++) and cinnamic alcohol (++). In particular, the latter was contained both in FM-1 and in the sunscreen as an ingredient. Photopatch tests were positive to KP (++), while UV filters such as fenticlor, octocrylene, benzophenone-3, 4 and 10 showed negative results. The photopatch test with cinnamic alcohol turned out negative.

Our KP-sensitive patient showed an ACD to a sunscreen containing cinnamic alcohol several days after its application. Various studies support the association between photocontact allergy to KP and contact sensitization to cinnamic alcohol, an ingredient of FM-1 [4-6]. This evidence can be explained by cross-reactivity between these substances [4, 5], but the mechanisms responsible for such cross-reactivity are still unknown. Nonetheless, some hypotheses, such as structural similarities or formation of common metabolites, have been proposed [4, 5].

Hence, our observations give rise to some recommendations: cinnamic alcohol may induce severe ACD in KP-sensitive patients, therefore they need to be aware of this risk and avoid sunscreens containing this fragrance.

Disclosure

Financial support: none. Conflict of interest: none.

References

1 A Offidani, A Cellini, P Amerio, O Simonetti, G. Bossi A case of persistent light reaction phenomenon to ketoprofen? Eur J Dermatol 2008; 10: 153-154.

2 M. Avenel-Audran Sunscreen products: finding the allergen… Eur J Dermatol 2010; 20: 161-166.

3 V Devleeschouwer, R Roelandts, M Garmyn, A. Goossens Allergic and photoallergic contact dermatitis from ketoprofen: results of (photo) patch testing and follow-up of 42 patients Contact Dermatitis 2008; 58: 159-166.

4 P Girardin, M Vigan, P Humbert, F. Aubin Cross-reactions in patch testing with ketoprofen, fragrance mix and cinnamic derivatives Contact Dermatitis 2006; 55: 126-128.

5 C Foti, D Bonamonte, A Conserva et al. Allergic and photoallergic contact dermatitis from ketoprofen: evaluation of cross-reactivities by a combination of photopatch testing and computerized conformational analysis Curr Pharm Des 2008; 14: 2833-2839.

6 L Stingeni, C Foti, N Cassano et al. Photocontact allergy to arylpropionic acid non-steroidal anti-inflammatory drugs in patients sensitized to fragrance mix I Contact Dermatitis 2010; 63: 108-110.