Complementary and alternative medicines are frequently used by the general population. Many people consider them to be without side effects. A case of allergic contact dermatitis and generalized urticaria and angioedema occurring in the same patient using topical Chinese herbal medicine and dietary supplements is described. A summary of allergic reactions to herbal medicine and dietary supplements is presented. Inquiry into the use of complementary and alternative medicine should be a standard part of history taking.
Some of the information contained in this article was presented at the Chinese Canadian Medical Society International Conference 2001, 29–30 September 2001, Vancouver, BC.
Patients concocting their own alternative treatment regimens are liable to allergic reactions, herb-herb interactions, and herb-drug interactions. This case report highlights the problem, and suggests ways to help patients avoid these adverse effects.
Allergic contact dermatitis from topical Chinese herbal medicine and generalized urticaria and angioedema from dietary supplementation: A case report
In a study conducted in 1997, 42% of the population in the United States used complementary and alternative medicine, including herbal medicine and dietary supplements. Because they are natural products—some with a long tradition of use—many people consider them safe and side-effect free. There are isolated reports of allergic reactions to herbal medicine and dietary supplements. A case of allergic contact dermatitis from a topical Chinese herbal medicine and generalized urticaria and angioedema from dietary supplements occurring in the same patient is described.
An 18-year-old Chinese patient applied a topical/external plaster, Riaxin, containing Chinese herbal medicine, for back pain. She used four plasters in sequence on two locations, each one being removed after 24 hours of application. The first one was applied on one location and the next three on the second location inferiorly on her lumbar spine. She developed pruritic erythematous papular eruption consistent with allergic contact dermatitis in the area of the plaster after the first application in the second location.
On the day of removal of the fourth plaster, she took two dietary supplements of mainly Western herbal content. They were Isotonix OPC-3, which she had taken daily about four times a week for the past year without previous reaction, and Tension Tamer Celestial Seasonings herb tea, which she was using for the first time. Within 15 minutes, she developed generalized urticaria and angioedema of her lips. There were no associated systemic features. She responded to prednisone 50 mg once daily for 9 days, mometasone furoate ointment 0.1%, and diphenhydramine hydrochloride 25 mg as needed, initiated by her family physician. She declined allergy-patch testing and oral challenge.
The ingredients of the external plaster, Riaxin (distributed by a natural product company in the US), include “all natural herbs,” Chinese herbs: Commiphora myrrha Engl., Panax notoginseng (Burk) F.H. Chen ex C. Chow, Impatiens balsamina L., Boswellia carterii Birdw, Clematis chinensis Osbeck, Liqusticum chuanxiong Hort., Acanthpanax gracilistylus W.W. Smith, Gentiana macrophylla Pall, and alcohol. The label on this preparation also includes warning of allergic contact skin reaction from its use.
The Isotonix OPC-3, manufactured in the US, claims to be “an isotonic capable dietary supplement” providing oligomeric proanthocyanidins. The ingredients include grape seed extract, red wine extract, pine bark extract (Pycnogenol), bilberry extract, citrus extract bioflavonoids, and potassium bicarbonate 93 mg in one capful. The label also states that “this product is not intended to diagnose, treat, cure, or prevent any disease.” This important statement is often not included in many other complementary and alternative medicine preparations.
The Tension Tamer Celestial Seasonings herb tea, also made in the US, contains chamomile flowers, Eleuthero ginseng root, peppermint leaves, cinnamon, ginger root, lemon grass, licorice root, catnip leaves, tilia flowers, natural lemon flavor, hops, and vitamins B6 and B12.
The allergic reactions associated with Chinese herbal medicine and Chinese patent medicine of herbal origin have recently been reviewed. They include Stevens-Johnson syndrome, generalized maculopapular eruption, acute urticaria, exanthematous eruption, and hypersensitivity myocarditis from oral preparations. A case of acute bronchospasm from occupational exposure from inhaled Chinese herbal medicine in a practitioner of complementary and alternative medicine has recently been presented.
The most common form of allergic reaction from Chinese herbal medicine is allergic contact dermatitis.[2,9] It is caused by topical Chinese patent medicine and prepackaged or freshly prepared topical Chinese herbal preparations from bone-setters who are Chinese kung fu masters treating rheumatic complaints or bone injuries.[8,10] Myrrh/mo yao is the putative allergen in allergic contact dermatitis from topical Chinese patent medicine. Patch testing, particularly for myrrh, would be helpful to establish the diagnosis.
Among Western herbal medicine and dietary supplements, there are occasional reports of allergic reactions. They include photosensitivity from St. John’s wort, hypersensitivity vasculitis from passion flower, Melaleuca oil (tea-tree oil) dermatitis, allergic skin reaction from echinacea and hops, bronchospasm from royal jelly, and lupus-like syndrome from yohimbine. Anaphylaxis has been reported in chamomile, including one fatal case.
The exact allergens causing allergic contact dermatitis and urticaria and angioedema in this patient are not clear as she declined patch testing and oral challenge. However, the topical external plaster, Riaxin, contains myrrh previously documented to be the putative allergen causing allergic contact dermatitis, and is most likely responsible for the allergic contact dermatitis in this patient.
The patient developed acute generalized urticaria and angioedema of her lips within 15 minutes of taking two dietary supplements. The patient had taken the Isotonix OPC-3 previously for 1 year without any reaction, and she took Tension Tamer Celestial Seasonings herb tea for the first time. It is highly suggestive that the urticaria and angioedema is due to the second dietary supplement, which contains chamomile, previously documented to cause anaphylaxis including urticaria and angioedema. The patient required high-dose oral prednisone, topical steroid, and antihistamines for management.
The specific components in the Chinese herbal medicine or dietary supplements causing allergic reactions are usually difficult to establish. There are additional problems of herbal plant misidentification, presence of prescription drugs, and unknown contents.[23,24] Although myrrh and chamomile are present in the topical Chinese herbal medicine and dietary supplements, the confirmative tests could not be carried out. In addition, myrrh as a testing antigen is not available in a local patch-testing clinic. Hops and licorice root may also be responsible, the latter present in an eight-herb preparation causing generalized maculopapular eruption.
Besides allergic reactions, complementary and alternative medicine, including herbal medicine and dietary supplements, can result in other adverse reactions, and herb-herb and herb-drug interactions.[25,26] Physicians should be familiar with complementary and alternative medicine literature,[27-29] and inquiry into the use of complementary and alternative medicine should be part of history taking. Patients should be given proper advice in the use of herbal medicine and dietary supplements, and be encouraged to tell physicians of their use of complementary and alternative medicine (see the Figure).
This is the first case report of two types of cutaneous allergic reaction to complementary and alternative medicine including topical Chinese herbal medicine and oral dietary supplements occurring in the same patient. Physicians should include inquiry into the use of complementary and alternative medicine as part of history taking. Complementary and alternative medicine (herbal medicine and dietary supplements), if used by the patient, should be included in the differential diagnosis in the presence of an allergic reaction.
The author would like to thank Dr Glen Bowlsby for the patient referral, the Medical Library Service of the College of Physicians and Surgeons of BC for the literature search, and Ms S. Hasham for secretarial aid.
Guidelines on using natural health products
• See your doctor to establish the cause of your illness and to discuss conventional treatments before you consider complementary and alternative medicine.
• Do not use herbal medicine if you are pregnant or breastfeeding.
• Always inform your doctor about the complementary and alternative medicines you are taking, and bring along all the pill bottles of prescription and non-prescription drugs and herbal or other dietary supplements when you see your doctor.
• Avoid using natural health products with exceptional claims, incomplete ingredient listings, testimonials, and no expiry dates.
• Look for disclaimers on natural health products.
• Even natural products can cause allergic and adverse reactions, can interact with each other or with conventional drugs, and can be toxic. Some examples include bleeding in Ginkgo when used with a blood thinner, nervous system and cardiovascular problems with ephedra/ephedrine, liver toxicity in kava, allergic reaction from bee pollen, and multiple drug interactions with St. John’s wort.
• Do not use more than the recommended dosage of a natural product, and do not use it longer than the recommended duration.
• Discontinue the use of a natural health product if you have an allergic or adverse reaction, or if your condition fails to improve or deteriorates. Report the situation to your doctor.
• Discontinue your natural health products at least 2 weeks prior to surgery because of potential effects on bleeding, blood pressure, and anesthetics.
• Remember, if you’re considering using a natural health product, you can always get a second opinion from your doctor.
—H.C. George Wong, MD
1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine in the United States, 1990–1997: Results of a follow-up national survey. JAMA 1998;280:1569-1575.PubMed Abstract
2. Wong HCG. Allergic reactions associated with Chinese herbal medicine. Allergy Asthma 2000,13:13-18.
3. Chosidow O, Dega H, Laporte J-L, et al. Ginseng as a cause for Stevens-Johnson syndrome? Lancet 1996;347:1344.PubMed Citation
4. Wong HCG. Generalized allergic maculopapular eruption associated with Prostate Gland Pills, a Chinese proprietary medicine of herbal origin. Ann R Coll Physicians Surg Can 2000;33:104-106.
5. Wong HCG. Acute urticaria associated with Chinese herbal medicine used for atopic dermatitis. Can J Allergy Clin Immunol 2001;6:77-79.
6. Li L-F, Zhao J, Li S-Y. Exanthematous drug eruption due to Chinese herbal medicine Sanjieling capsule and Houoxuexiaoyan pill. Contact Dermatitis 1993;29:279.PubMed Citation
7. Zaacks SM, Klein L, Tan CD, et al. Hypersensitivity myocarditis associated with ephedra use. J Toxicol Clin Toxicol 1999;37:485-489.PubMed Abstract
8. Wong HCG, Wong NYY, Wong JKT. Bronchospasm from inhaled Chinese herbal medicine in a practitioner of complementary and alternative medicine (CAM). Abstract Book of the 2nd Annual International Poster Competition sponsored by ACP-ASIM in Conjunction with the International Society of Internal Medicine (ISIM). ACP Annual Session 2001, Atlanta, USA, 29–31 March 2001.
9. Leow YH. Contact dermatitis due to topical traditional Chinese medication. Clinics Dermatol 1997;15:601-605.PubMed Citation
10. Ng SK. Topical traditional Chinese medicine, a report from Singapore. Arch Dermatol 1998;134:1395-1396.PubMed Abstract
11. Lee TY, Lam TH. Myrrh is the putative allergen in bonesetter’s herb dermatitis. Contact Dermatitis 1993;29:279.PubMed Citation
12. Brockmoller J, Reum T, Bauer S, et al. Hypericin and pseudohypericin: Pharmacokinetics and effects on photosensitivity in humans. Pharmacopsychiatry 1997;30:94-101.PubMed Abstract
13. Smith GW, Chalmers TM, Nuki G. Vasculitis associated with herbal preparation containing Passiflora extract. Br J Rheumatol 1993;32:87-88.PubMed Citation
14. Knight TE, Hausen BM. Melaleuca oil (tea tree oil) dermatitis. J Am Acad Dermatol 1994;30:423-427.PubMed Abstract
15. De Smet PAGM. Health risks of herbal remedies. Drug Safety 1995;13:81-93.PubMed Abstract
16. Newmark FM. Hops allergy and terepene sensitivity: An occupational disease. Ann Allergy 1978;41:311-312.PubMed Citation
17. Perharic L, Shaw D, Murray V. Toxic effects of herbal medicine and food supplements. Lancet 1993;342:180-181.PubMed Citation
18. Sandler B, Aronson P. Yohimbine-induced cutaneous drug eruption, progressive renal failure, and lupus-like syndrome. Urology 1993;41:343-345.PubMed Abstract
19. Benner MH. Lee HJ. Anaphylactic reaction to chamomile tea. J Allergy Clin Immunol 1973;52:307-308.PubMed Citation
20. Jensen-Jarolim E, Reider N, Fritsch R, et al. Fatal outcome of anaphylaxis to chamomile-containing enema during labor: A case study. J Allergy Clin Immunol 1998;102(6 pt 1):1041-1042.PubMed Citation
21. Wong HCG. Probable false authentication of herbal plants: Ginseng. Arch Intern Med 1999;159:1142-1143.PubMed Citation
22. Wong HCG. Potential adverse reaction from patent medicines containing prescription drugs purchased in local Chinese herbal shops used by three patients [Abstract 44]. J Allergy Clin Immunol 2001;107:S14.
23. Wong HCG. Chinese herbal medicine and allergy. ACI International 2001;13:192-196. Abstract
24. Wong HCG. Chinese patent medicines (Zhong Cheng Yao) of herbal and unknown origin used for allergic and other conditions. Can J Allergy Clin Immunol 2001;6:162-165.
25. Angell M, Kassirer JP. Alternative medicine—The risks of untested and unregulated remedies. N Engl J Med 1998;339:839-841.PubMed Citation
26. Miller LG. Herbal medicinals—Selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med 1998;158:2200-2211.PubMed Abstract
27. Wong HCG, Neill JC. Physician use of complementary and alternative medicine (CAM) literature. Complement Ther Med 2001;9:173-177.PubMed Abstract
28. Wong HCG. Adverse and allergic reaction in complementary and alternative medicine. J Allergy Clin Immunol 2001;108:149-150.PubMed Citation Full Text
29. Wong HCG. Potential adverse and allergic reaction from complementary and alternative medicine (CAM) and other dietary supplements (DS). Can J Clin Imunol 2001;6:196-197.
30. Wong HCG. Approach to the use of herbal medicine. Allergy Asthma 2000,13:19-20.
H.C. George Wong, MD, FRCPC, FACP, FAAAAI
Dr Wong is a clinical associate professor in the Division of Allergy and Immunology in the Department of Medicine at the University of British Columbia, course director of the UBC CME Community-Based Allergy/Immunology Program, active staff at Vancouver General Hospital, and a member of the BCMA’s Alternative Therapies and Allied Health Committee.
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