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Systemic Contact Dermatitis to Spices: Report Of A Rare Case

December 2021
Contact Dermatitis

DOI:10.1111/cod.14031

Authors:

Rohit Kothari

Centre for Blistering Diseases

Karthi Kishore

Military Hospital Shillong

Sunmeet Sandhu

Armed Forces Medical College

Anuj Bhatnagar

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Systemic contact dermatitis (SCD) or systemically reactivated allergic contact dermatitis (ACD) is a hypersensitivity reaction caused by systemic exposure to a same or related allergen in an already sensitized person. The initial sensitization is by cutaneous route, followed by exposure via oral, intramuscular, intravenous, inhalation route or percutaneous exposure through inflamed/broken skin/mucosa. SCD to spices is not common and may even be misdiagnosed/overlooked in the absence of a detailed history or high degree of suspicion. We report an unusual case of SCD that developed following oral ingestion of paste of green chilli, garlic and ginger which is very commonly used in household recipes.

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CONTACT POINT

Systemic contact dermatitis to spices: Report of a rare case

Rohit Kothari

| Karthi Kishore

| Sunmeet Sandhu

| Anuj Bhatnagar

Reetika Pal

| Satish Chand

Department of Dermatology, Command Hospital Air Force, Bengaluru, India

Department of Dermatology, 7 Air Force Hospital, Kanpur, India

Correspondence

Dr Rohit Kothari, Senior Resident, Department of Dermatology, Command Hospital Air Force, Bengaluru 560007, Karnataka, India.

Email: rohitkothari3422@gmail.com

KEYWORDS: case report, patch test, spices, systemic contact dermatitis

Systemic contact dermatitis (SCD) or systemically reactivated allergic

contact dermatitis (ACD) is a hypersensitivity reaction caused by systemic

exposure to the same or related allergen in an already sensitized person.

The initial sensitization is by a cutaneous route, followed by re-exposure

via oral, intramuscular, or intravenous, inhalation, or percutaneous

exposure through inflamed/broken skin/mucosa.

1,2

SCDtospicesisnot

common and may even be misdiagnosed or overlooked in the absence of

a detailed history or high degree of suspicion.

We report an unusual

case of SCD that developed following oral ingestion of a green chilli,

garlic, and ginger paste, which is commonly used in household recipes.

FIGURE 1 (A) Multiple

discrete to confluent vesicles and

erythema over right forearm, (B)

diffuse erythematous

maculopapular rash over neck,

upper chest and (C) upper lip

philtrum

Received: 2 November 2021 Revised: 16 December 2021 Accepted: 21 December 2021

DOI: 10.1111/cod.14031

CASE REPORT

A 28-year-old, otherwise healthy female presented with complaints

of multiple itchy vesicles and erythema over her right forearm

(Figure 1A) within 12-hours following accidental contact with green

chilli, garlic, and ginger paste (through spillage). This was followed

by a severely itchy erythematous maculopapular rash over her neck,

upper chest (Figure 1B), upper lip philtrum (Figure 1C), and diffuse

erythema over both cubital fossa (right>left) (Figure 2A). She also

presented the next day with a few erythematous papules over both

popliteal fossa (Figure 2B) and inframammary region within

2-3 hours following consumption of a freshly made paste of the

same ingredients. The patient reported using the paste consisting of

the same ingredients previously in the last 1 year. She also admitted

to always preparing the paste barehanded, which may have led to

the initial cutaneous sensitization. She was diagnosed with SCD to

ingredients in the paste and was managed with a short course of

oral steroids and antihistamines. The lesions resolved completely

within a week. A patch test was performed after 4 weeks with

extracts of all the ingredients of the paste prepared in the labora-

tory: 10 g each of peeled garlic cloves, peeled ginger, and green

chilli crushed with 10 mL of distilled water and kept overnight at

room temperature. The next morning the solution was filtered to

obtain the extract. Commercially available Indian standard series-

fragrance mix was used for testing for any fragrance allergy. The

patch test showed an extreme, positive reaction only to green chilli

on day 3 with multiple coalescing vesicles that ruptured to form an

erosion (3+)(Figure2C).Thepatient’s husband, parents, and two

brothers were also patch tested with the same extracts, as controls

and a negative reaction was seen to all the ingredients in all family

members. The patient was counselled to avoid these ingredients

in future.

DISCUSSION

Various reaction patterns can occur in patients with SCD, which should

be suspected in cases with persistent dermatitis, even with avoidance of

cutaneous exposure to the allergen. The most common pattern is vesic-

ular hand eczema, others being acral or flexural erythema.

SCD induced

by spices is an uncommon phenomenon and where this does occur, car-

damom, cinnamon, mace and black pepper may be the culprits.

Colo-

phony, balsam of Peru, and fragrance mix might be contact sensitizers in

individuals who have SCD to spices such as clove, nutmeg, cinnamon,

and cayenne pepper. Protein contact dermatitis has been reported with

paprika and curry, usually containing a mix of spices, such as coriander

and pepper, that may or may not disappear following cooking,

depending upon the different allergenic epitopes.

A thorough literature

search revealed scarce data on SCD with any of the ingredients con-

sumed by the patient. Green chilli (Capsicum annuum) contains

1,3-Beta-glucanase, which may cause ACD and contact urticaria.

It is

possible that this allergen could have led to the allergic response in our

patient. This may have been a type-IV hypersensitivity reaction;

evidence favouring a type-III hypersensitivity reaction was insufficient.

This case report highlights important factors to be considered when

evaluating a case of generalized dermatitis, the importance of patch

tests, and the role of spices and various ingredients used regularly in

food, which may be one of the less commonly known triggers of SCD.

ACKNOWLEDGEMENTS

The patient gave written informed consent to the publication of her

case details and photographs.

AUTHOR CONTRIBUTIONS

Rohit Kothari: Conceptualization (lead); data curation (lead); formal

analysis (lead); investigation (lead); methodology (lead). Karthi

FIGURE 2 (A) Diffuse

erythema over both cubital fossa

(right>left), (B) few erythematous

papules over both popliteal fossa

(black arrows) and (C) positive

patch test (3+) to green chilli

2KOTHARI ET AL.

Kishore: Conceptualization (equal); data curation (equal); formal analy-

sis (equal); investigation (equal); methodology (equal). Sunmeet

Sandhu: Conceptualization (equal); data curation (equal); formal analy-

sis (equal); investigation (equal); methodology (equal). Anuj Bhatnagar:

Conceptualization (equal); data curation (equal); formal analysis

(equal); investigation (equal); methodology (equal). Reetika Pal:

Conceptualization (equal); data curation (equal); formal analysis

(equal); investigation (equal); methodology (equal). Satish Chand:

Conceptualization (equal); data curation (equal); formal analysis

(equal); investigation (equal); methodology (equal).

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the

corresponding author upon reasonable request.

ORCID

Rohit Kothari https://orcid.org/0000-0002-9875-2563

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How to cite this article: Kothari R, Kishore K, Sandhu S,

Bhatnagar A, Pal R, Chand S. Systemic contact dermatitis to

spices: Report of a rare case. Contact Dermatitis. 2022;1-3.

doi:10.1111/cod.14031

KOTHARI ET AL.3

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A survey of plants responsible for causing allergic contact dermatitis in the Amathole District, Eastern Cape, South Africa

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Ethnopharmacological relevance: Potentially harmful plants grow almost everywhere, hence, it is not practical to eradicate them all. However, a basic understanding of adverse cutaneous reactions and the common plants that cause each type can enable vulnerable individuals to discover the source of their dermatitis and thus prevent re-exposure. The aim of this study therefore, was to document the plants responsible for irritant contact dermatitis (ICD) in the Eastern Cape, along with their respective irritants and clinical presentations. Materials and methods: Study participants (161) in 12 locations were selected by convenient sampling with particular focus on local people who regularly interact with plants or plant products. Interview questions were focused on the local names of plants that contain irritating chemicals and physical characteristics that cause ICD. Results: Forty four plant species distributed in 24 families and 34 genera were reported as causative agents of irritant contact dermatitis. Herbs constituted 67.35%, trees 24.49% and shrubs 8.16%. Mechanical ICD was reported to be caused by 23 species, closely followed by chemical ICD (20 species) and mechanico-chemical ICD (6 species). Species with the highest frequency of citations were Allium cepa, Acacia karroo, Capsicum annuum, Citrus limon and Zea mays. The most representative families were Euphorbiaceae (for chemical ICD), Urticaceae (for mechanico-chemical ICD), Fabaceae and Rutaceae for mechanical ICD. Most of the classes of chemical compounds identified as being responsible for chemical ICD were restricted to plants of specific genera such as the diterpenes in Euphorbia spp., disulphides in Allium spp., terpenes in Citrus spp. and isothiocyanates in Brassica spp. Thorns and hairs were reported for causing Mechanical ICD in 6 plant species each, including widely cultivated plants such as Acacia karoo and Citrus reticulata. Conclusion: Irritant contact dermatitis is a common cutaneous disorder in individuals exposed to plants in the Eastern Cape, especially among workers of the food and flower industries. Health practitioners should therefore consider the possible work-related causes of dermatitis, especially in cases associated with a clear history of symptoms.

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Contact and systemic contact-type dermatitis reactions to spices such as nutmeg, mace, cardamom, curry, cinnamon, and laurel may be rare but may well be overlooked. In our experience, patch testing with these spices "as is" is very useful; if there is a positive reaction, testing with dilutions is helpful. Scratch-chamber testing often leads to false-positive irritant reactions. As Hjorth and Niinimäki have pointed out, a positive test to balsam of Peru may indicate a spice allergy, but the absence of such a reaction does not rule it out. In all the cases in our experience, the careful drafting of the anamnesis or case history was critical in the diagnosis.

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