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Tongue erosions and diet cola.


We report the case of a 38-year-old woman who presented with a 10-year history of painful ulcerations on her tongue. She reported that she drank large quantities of diet cola and some orange juice daily and that she used cinnamon-flavored toothpaste and mouthwash nightly. Patch testing elicited positive reactions to balsam of Peru (a fragrance as well as a flavoring agent put in cola drinks that cross-reacts with orange juice) and cinnamic aldehyde. She was diagnosed with allergic contact dermatitis. She was put on a restricted diet and a fragrance-free regimen, and her condition resolved.


Allergic contact dermatitis is a T-lymphocyte-mediated allergic (hypersensitivity) reaction to sensitizing chemicals in the environment. In 2004, 72 million Americans were seen in dermatology outpatient clinics for management of this condition. (1) Allergic contact dermatitis can be caused by a wide range of chemicals--from nickel (a metal) to rubber-based compounds to balsam of Peru (a fragrance and flavoring agent). We describe a case that was attributed to the latter.

Case report

A 38-year-old woman with Fitzpatrick skin type I presented to our contact dermatitis clinic with a 10-year history of painful ulcerations on her tongue. The ulcers would wax and wane; when they recurred, they usually did so at the same locations. The patient denied similar lesions on her vulva and eyes. She had not taken any medications, nor was she known to be allergic to any medications. She reported that she consumed orange juice daily with breakfast and that she drank at least one six-pack of diet cola throughout the remainder of each day. She also used cinnamon-flavored toothpaste and mouthwash at night.

Physical examination revealed the presence of several well-circumscribed erosions on the patient's tongue (figure 1) and on the buccal mucosa. Also, lichenified plaques were seen on her neck and wrists. The differential diagnosis included Behcet's disease, cicatricial pemphigoid, a fixed drug reaction, and allergic contact dermatitis.


A punch biopsy of the tongue lesion identified chronic dermatitis; direct immunofluorescence revealed no immunoglobulin or complement deposition. A shave biopsy of a neck plaque identified a hyperkeratotic, acanthotic, spongiotic dermatitis with lymphocytes and scattered eosinophils. The results of patch testing were read at 48 and 96 hours; testing elicited positive reactions to balsam of Peru and to one of its components, cinnamic aldehyde (figure 2). The patient was diagnosed with allergic contact dermatitis.


The patient was placed on a fragrance-free regimen and a restricted diet designed to eliminate foods rich in balsam of Peru--based chemicals (table), which include citrus products, cola drinks, and cinnamon. On this diet, her oral erosions cleared and there was a dramatic improvement in her neck and wrist dermatitis. At follow-up, she was further counseled on the need to avoid fragrances because of their potential cross-reactivity with balsam of Peru. (2)


This case demonstrates the inherent value of patch testing, which is the diagnostic gold standard, and the importance of allergen avoidance once the eliciting chemical allergen has been identified.

Balsam of Peru is a gum resin extracted from the Myroxylon balsamum tree, which is native to South and Central America. The recorded use of balsam dates back to the Inca empire (ca. 1200-1500 A.D.), when it was used to treat lung maladies. In the 1500s, Spanish missionaries in Peru valued it as a sacramental ointment and began exporting it to Europe. It was at this time that the Europeans gave it its current name. (3)

Balsam of Peru is a complex substance made up of volatile oils and resins. The main active ingredients are believed to be benzoic acid and cinnamic acid esters in the oil. Today, it is used in the manufacture of pharmaceutical and cosmetic products. Because it has antibacterial effects, it is used as a topical treatment for wounds. It is also used to treat hemorrhoids. Its aroma is similar to that of both cinnamon and vanilla, which renders it a popular ingredient for perfumes and sunscreens. Finally, the food and beverage industries use it to augment some of their products; it is found naturally in others (table). Balsam of Peru can cross-react with various foods as well as with other substances--for example, turpentine.

With regard to the other initial differential diagnoses in this case:

* Behcet's disease is an inflammatory disorder. It is marked by the occurrence of oral ulcers at least three times within a 12-month period in addition to two of the following conditions: posterior uveitis, genital ulceration, erythema nodosum, and positive pathergy findings.

* Cicatricial pemphigoid (benign mucosal pemphigoid) is an autoimmune disorder characterized by the presence of evanescent vesicles that rupture and become erosions, primarily on the mucous membranes. Direct immunofluorescence testing of lesional or perilesional skin reveals IgG and C3 complement at the lamina lucida.

* A fixed drug reaction is an allergic reaction to a particular medication that occurs at the same location whenever that medication is taken. The reaction manifests as the appearance of targetoid lesions that erode and recur at the same site. Approximately 50% of these reactions occur on the oral and genital mucosa. (4)


(1.) The Lewin Group. The burden of skin diseases 2004. At http:// (in pdf format; access verified Jan. 29, 2007).

(2.) Fisher AA. Perfume dermatitis in children sensitized to balsam of Peru in topical agents. Cuffs 1990;45:21-3.

(3.) Hjorth N. Eczematous allergy to balsams, allied perfumes and flavouring agents, with special reference to balsam of Peru. Acta Derm Venereol Suppl (Stockh) 1961;41(supp146): 1-216.

(4.) Odom RB, James WD, Berger TG. Andrews' Diseases of the Skin: Clinical Dermatology. 9th ed. Philadelphia: W.B. Saunders; 2000:134-5, 594-7, 1008-10.

Sharon E. Jacob, MD; Tace Steele, BA

From the Contact Dermatitis Clinic, Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Florida.

Reprint requests: Sharon E. Jacob, MD, 1295 N.W. 14th St., Miami, FL 33125. Phone: (305) 243-4472; fax: (305) 243-6191; e-mail:
Table. Foods that contain or cross-react with balsam
of Peru

Chili peppers
Citrus fruit and its products
Cola and spiced sodas (e.g., Dr. Pepper)
Ice cream
Menthol flavoring
Tomatoes and foods with tomato products (e.g., catsup)
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Article Details
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Author:Steele, Tace
Publication:Ear, Nose and Throat Journal
Date:Apr 1, 2007
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