Balsam of Peru Avoidance Diet
When Allergy to Fragrance Additives Means Allergy to Tomatoes and Cinnamon: The Balsam of Peru Avoidance Diet
"I know I'm allergic to lotions with fragrance. I'm pretty sure I'm allergic to tomatoes too."
This may sound surprising, but it's entirely possible. Fragrance additives are chemically related to several foods, such as tomatoes, citrus, and cinnamon.
While some may wrongly blame food and diet for their skin problems, there are some situations in which testing can be recommended. These situations also include cases of suspected systemic contact dermatitis (SCD), a specific type of allergy triggered by food. By using patch testing, a process in which substances which may trigger allergic reactions are applied to ones back, the skin will then be examined for allergic reactions.1
Systemic Contact Dermatitis: When Foods Trigger Inflammation of the Skin
SCD traditionally refers to a skin condition where an individual who is cutaneously sensitized to an allergen will subsequently react to that same allergen or a cross reacting allergen via a different route, such as through consumption of foods containing the allergen.2 This is in contrast to allergic contact dermatitis (ACD), where an allergic reaction forms as a result of the substance touching the skin. Examples may include poison ivy causing itching and a rash, or skin care products causing irritation to the skin.
Conversely, SCD may be caused by an all-natural substance referred to as balsam of Peru (BOP). Derived from trees found in Central America, it contains a mixture of many substances that are generally related to cinnamon, vanilla, and clove fragrances and flavorings.3 If consumed by an individual who is allergic, they may develop rashes on the face, lips, hands, and genital area.
For Patients Allergic to Fragrance Additives, Changing Your Diet Might Help
If your dermatologist suspects that you're allergic to skin care products or other external exposures, they'll recommend patch testing. Studies have found that among patients undergoing patch testing, fragrance additives are one of the most common allergens. If there are positive results indicating sensitivity to certain fragrances, they may recommend complete avoidance of fragrance additives in skin care products. This is easier said than done, since a product labeled “fragrance-free” may still contain fragrance additives due to marketing regulations. If the patient successfully avoids fragrances for eight weeks and still experiences skin inflammation, then diet change may be beneficial.
The Balsam of Peru Avoidance Diet
In a study by Salam et al., patients with chronic dermatitis and an allergy to fragrance additives underwent diagnostic patch testing for balsam of Peru (BOP), fragrance mix (FM), cinnamic aldehyde, and Tolu balsam. Those with positive reactions were selected to complete the study in which they were asked to follow a diet absent of all foods chemically related to fragrance, known as the balsam of Peru avoidance diet (Table 1).
Table 1. Balsam of Peru Diet (Foods to Avoid)
- Products containing citrus (grapefruit, lemons, tangerines, oranges)
- Flavoring agents as found in baked goods, candy, and gum
- Spices including cinnamon, vanilla, curry, cloves, anise, ginger, and allspice
- Spicy condiments such chili sauce, ketchup, barbecue sauce, and chutney
- Pickles and pickled vegetables
- Beer, wine, gin, and vermouth
- Flavored or perfumed tea and tobacco i.e., mentholated tobacco
- Some cough medicines and lozenges
- Ice cream
- Chili, pizza, Mexican and Italian food with red sauces
- Tomatoes and tomato-containing products
They found that after six weeks of following the diet, of the 45 patients studied, close to half had complete or significant improvement in their dermatitis. The most commonly reported triggers of dermatitis were tomatoes (33%), citrus (30%), spices, including vanilla (23%), cola/soda (17%), and chocolate (17%).4 The three most frequently reported sites of dermatitis in this series were the hands, face, and anogenital regions, all with the same frequency of 31%.4
There are a number of different foods and beverages that should be avoided while on the BOP diet. The main culprits are any foods containing tomatoes, citrus, and cinnamon. In the clinical context, many patients with BOP allergy report allergic reactions after consuming tomatoes, particularly tomato sauce found in pizza or spaghetti. Other instances are when cinnamon is consumed sprinkled on coffee, oatmeal, or in baked goods. Vanilla and cloves can also be found in baked goods and have to be monitored when on the BOP diet. Citrus fruits, such as lemons, oranges, or those in juices are another frequent trigger. Unfortunately, chocolate is another trigger, along with common flavorings in soft drinks, flavored teas, and liquor.
Figure 1. The Balsam of Peru Avoidance Diet
Reprinted with permission from www.SkinAndDiet.com
The Need for Patience: Improvement May Take Up to 6 Weeks or Longer
Recovering from SCD can be a slow process, as is the case in recovering from exposure to any allergy-causing substances. It is recommended that the BOP elimination diet be followed for at least six weeks, after which foods can be re-introduced slowly and one at a time. Every few days, a food is re-added and the symptoms are monitored to see if they are able to pinpoint particular trigger foods. The slow nature of the process is partially due to the slow onset of flare up after consuming the triggering food. For example, if one is allergic to cinnamon, one does not get an immediate flare up and experience burning of the skin right away. It may take a few hours to days for the dermatitis to manifest. It is also important to note that most do not react to every food on the BOP list. Many patients report that only a few foods seem to act as triggers.
Patients allergic to fragrance additives or balsam of Peru on patch testing can discuss with their dermatologist whether or not the BOP avoidance diet is right for them. This is especially so if avoidance of fragrance and cross-reactants in topical skin care products does not resolve ongoing dermatitis.
- Patch testing and contact dermatitis. SLU. (n.d.). Retrieved September 20, 2021, from https://www.slucare.edu/dermatology/general-dermatology/patch-testing.php.
- Aquino M, Rosner G. Systemic Contact Dermatitis. Clin Rev Allergy Immunol. 2019 Feb;56(1):9-18. doi: 10.1007/s12016-018-8686-z. PMID: 29766368.
- Balsam of Peru. Balsam of Peru | Allergic Contact Dermatitis Database. (n.d.). Retrieved September 21, 2021, from https://www.contactdermatitisinstitute.com/balsam-of-peru-myroxylon-pereirae-resin.php.
- Salam TN, Fowler JF Jr. Balsam-related systemic contact dermatitis. J Am Acad Dermatol. 2001 Sep;45(3):377-81. doi: 10.1067/mjd.2001.114738. PMID: 11511833.