Balsam of peru allergy what can i eat

Among the alternate names used for Balsam of Peru are: Balsamum peruvianim, Black balsam, China oil, Honduras balsam, Indian balsam, Peruvian balsam, Peru balsam, Surinam balsam, Balsams Peru, Balsam Peru oil, Oil balsam Peru, Peru balsam oil, Balsamum Peruvianum, Bálsamo del Perú, Baume du Pérou, Baume Péruvien, Baume de San Salvador, Myroxylon pereirae klotzsch resin, Myroxylon balsamum var. pereirae, Myroxylon pereirae klotzsch oil, Myrospermum pereirae, Myrosperum pereira balsam, balsam fir oleoresin, balsam fir oil, hyperabsolute balsam, Quina, Balsamo, Tolu, Quina quina, Santos Mahogany, Toluifera pereirae, and Toluifera pereira balsam.[9][28][45]


Allergy

A number of national and international surveys own identified Balsam of Peru as being in the «top five» allergens most commonly causing patch test reactions in people referred to dermatology clinics.[15][24][25] A study in 2001 found that 3.8% of the general population patch tested was allergic to it.[26] Numerous flavorings and perfumes contain components identical to Balsam of Peru.[27] It may cause redness, swelling, itching, and blisters.[28][29]

People allergic to Balsam of Peru, or other chemically related substances, may experience a contact dermatitis reaction.[9] If they own oral exposure, they may experience stomatitis (inflammation and soreness of the mouth or tongue), and cheilitis (inflammation, rash, or painful erosion of the lips, oropharyngealmucosa, or angles of their mouth).[9][15][24] If they ingest it, they may experience pruritus and contact dermatitis in the perianal region, possibly due to unabsorbed substances in the feces.[15][30] It can cause a flare-up of hand eczema.[9] Among the other allergic reactions to Balsam of Peru are generalized or resistant plantardermatitis, rhinitis, and conjunctivitis,[15][31] In a case study in Switzerland, a lady who was allergic to Balsam of Peru was allergic to her boyfriend’s semen following intercourse, after he drank large amounts of Coca-Cola.[32]

A positive patch test is used to diagnose an allergy to Balsam of Peru.[9][14][30] Positive patch test results indicate that the person may own problems with certain flavorings, medications, and perfumed products.[9] Among foods, the most commonly implicated are spices, citrus, and tomatoes.[33]

People allergic to Balsam of Peru may benefit from a diet in which they avoid ingesting foods that contain it.[15] Naturally occurring ingredients may contain substances identical to or extremely closely related to Balsam of Peru, and may cause the same allergic reactions.[11] In some instances, Balsam of Peru is listed on the ingredient label of a product by one of its various names, but it may not be required to be listed by its name by mandatory labeling conventions (in fragrances, for example, it may simply be covered by an ingredient listing of «fragrance»).[11][34][35][36][37] To determine if Balsam of Peru is in a product, often doctors own to contact the manufacturer of the products used by the patient.[38]

Before 1977, the main recommended marker for perfume allergy was Balsam of Peru, which is still advised.

The presence of Balsam of Peru in a cosmetic will be denoted by the INCI term Myroxylon pereirae.[10]

Because of allergic reactions, since 1982 crude Balsam of Peru has been banned by the International Perfume Association from use as a perfume compound, but extracts and distillates are used up to a maximum level of 0.4% in products, and are not covered by mandatory labeling.[27]

In March 2006, the European Commission, Health and Consumer Protection Directorate-General, Scientific Committee on Consumer Products, issued an Opinion on Peru Balsam.[39] It confirmed that crude Peru Balsam should not be used as a perfume ingredient, because of a wide variety of test results on its sensitizing potential, but that extracts and distillates can be used up to a maximum level of 0.4% in products.[39]


History

«Balsam of Peru» is a misnomer.[40] In the early period of Spanish invasion in Central and South America, the balsam was collected in Central America and shipped to Callao and Lima in Peru, then shipped onward to Europe.[40][41][42] It acquired the name of «Peru» because it was shipped from there.[40][41] Its export to Europe was first documented in the seventeenth century in the German Pharmacopedia.

Today it is extracted under a handicraft process, and is mainly exported from El Salvador.[43] The two balsams obtained from Myroxylon sp. trees, Balsam of Peru and Tolu Balsam (not «Balsam of tolú»).[44] are produced in diverse ways (see Myroxylon). «Tolu Balsam» is not a misnomer but rather a toponymy since the balsam was actually obtained from the latex of a tree originally described by Linnaeus as Toluifera balsamum later known as Myroxilon balsamum.[44] In 1753 Linnaeus described the type specimen of Toluifera balsamum using a specimen collected in the province of Cartagena, probably a town called Tolú, which at the time was located in the province of Cartagena, and named it Toluifera balsamum in relation to the put of collection.[44] In ecological terms, Tolu region can be described, according to Holddrige classification as Tropical Dry Forest, which is home to Myroxylon sp. trees.

Balsam of peru allergy what can i eat


Composition

Balsam of Peru contains 25 or so diverse substances,[8] including cinnamein, cinnamic acid, cinnamyl cinnamate, benzyl benzoate, benzoic acid, and vanillin.[1][9] It also contains cinnamic acid alcohol and aldehyde, farnesol, and nerolidol.[10] A minority of it, approximately 30–40%, contains resins or esters of unknown composition.[9]


Collection

Balsam of Peru is an aromatic viscous resin obtained by scorching or inflicting V-shaped wounds on the bark of the trunk of the tree Myroxylon balsamum var.

pereirae.[1][4][5] In response, the Balsam of Peru – oily, resin-like, aromatic fluid – exudes to heal the tree’s lesions, and the liquid is collected.[1][6][7] An essential oil is distilled from the balsam.


Uses

Balsam of Peru is used in food and drink for flavoring, in perfumes and toiletries for perfume, and in medicine and pharmaceutical items for healing properties.[9]

In some cases, it is listed on the ingredient label of a product by one of its various names.[11] Naturally occurring ingredients may contain substances identical to or extremely closely related to Balsam of Peru.[11]

It has four primary uses:

  1. fragrance in perfumes and toiletries, such as perfumes, colognes, deodorants, soaps, shampoos, conditioners, after-shave lotions, cosmetics, lipsticks, creams, lotions, ointments, baby powders, sunscreens, and suntan lotions
  2. in medicinal products such as hemorrhoid suppositories and ointment, cough medicine/suppressant and lozenges, diaper rash ointments, oral and lip ointments, tincture of benzoin, wound spray (it has been reported to inhibit Mycobacterium tuberculosis as well as the common ulcer-causing bacteria H.

    pylori in test-tube studies), calamine lotion, surgical dressings, dental cement, eugenol used by dentists, some periodontal impression materials, and in the treatment of dry socket in dentistry.[1][9][12][13][14][15][16][17][18]

  3. flavoring in foods and drinks such as coffee, flavored tea, wine, beer, gin, liqueurs, apéritifs (e.g., vermouth, bitters), soft drinks including cola, juice, citrus, citrus fruit peel, marmalade, tomatoes and tomato-containing products, Mexican and Italian foods with red sauces, ketchup, spices (e.g., cloves, Jamaica pepper (allspice), cinnamon, nutmeg, paprika, curry, anise, and ginger), chili sauce, barbecue sauce, chutney, pickles, pickled vegetables, chocolate, vanilla, baked goods and pastries, pudding, ice cream, chewing gum, and candy
  4. optical properties as a glue, typically as a mounting medium for microscope specimens[19][20] due to purified Balsam of Peru’s transparency and refractive index of 1.597 being extremely shut to that of numerous glasses used in optics[21]

It also can be found in toothpaste, mouthwash, scented tobacco, cleaning products, pesticides, insect repellants, air fresheners and deodorizers, scented candles, and oil paint.[12][22][23]



Atllergic contact dermatitis (ACD) is an significant disease that notably affects 14.5 million Americans each year.1 The economic impact of this disease is high in terms of both patient morbidity and loss of income, school and work, not to mention significant expenditures for visits to healthcare providers and for medicaments.

A correct diagnosis of ACD will improve, prevent or “cure” the dermatitis and decrease overall costs to the healthcare system.1 Once patch testing is performed and a culprit has been identified, education becomes the critical intervention to ensure adherence to an avoidance regimen. With allergen avoidance, remission of the dermatitis ensues. If patients are unable to comply with the avoidance regimen, they become at risk for recurrent or sustained dermatitis or progression to a systematized presentation.2,3

The 2 main types of contact dermatitis are irritant and allergic, with irritant contact dermatitis (ICD) being the most common.

ICD may happen in anyone who is exposed to an irritating substance with significant duration or in significant concentrations such as chronic or frequent water exposure, abrasive cleansers, detergents and soaps. It is significant to note that ICD can at times precede or be a concomitant diagnosis with ACD.4,5 ACD is a delayed-type-IV hypersensitivity reaction that can happen due to a large number of chemicals from poison ivy to fragrances in shampoos. The evaluation of ACD fits well with theranostic theory, as the epicutaneous patch test diagnostic evaluation dictates the avoidance management in each individual patient.

Although ACD is not “curable,” numerous individuals will achieve finish remission with assiduous avoidance.

In this article, we highlight ACD and explore top relevant allergens, regional-based dermatitis presentations, topic-based dermatitis presentations and clinical tips and pearls for diagnosis and treatment. This article will focus on Myroxylon pereirae (MP).

Myroxylon Pereirae: A Brief History

MP, aka balsam of Peru (BOP), has remained 1 of the 5 most prevalent allergens detected by both the thin-layer rapid use epicutaneous (TRUE) test and the North American Contact Dermatitis Group over the final decade.6,7 Notably, the first cutaneous allergic manifestation was described by Mögling in 1880, well after it had been used in Europe for over 300 years.8

BOP was so named because it was originally shipped to Europe from the port of Callao in Peru; however, the tree does not grow in Peru.

This tree is native to present day El Salvador9 and goes by a number of other names (Table 1). The sap was so highly prized as a sacramental ointment by the Spanish clergy that a papal decree was issued in 1562 that prohibit the destruction of the balsam trees. Notably, since the times of the Incan Empire, the balsam extracts own been used to relieve bronchitis, colds, coughs, fevers and infections. The Aztecs were among the first to cultivate the tree in their royal gardens make to compresses with the mashed leaves to speed the healing of wounds.10

Modern Utilization

The modern usages of MP include 3 major applications in the pharmaceutical, perfume and flavoring industries.

Notably, because of its mild bactericidal action and capillary-bed stimulant effects, MP is widely used in topical medicines for wounds, burns and hemorrhoids. In the perfume industry, MP (or a cross-reacting derivative) may be used in a variety of consumer products from aftershave lotions, baby diaper salves and powders to deodorants, fragranced bathing products, hair products, perfumes and sunscreens (Table 2). MP may also be found in “flavored” tobacco, coffees and teas, and in a significant number of foods.

The Composition of Myroxylon Pereirae

MP is a dark brown, complicated viscid fluid that is exuded from the wounded mature Myroxylon balsamum tree.

El Salvador, the main exporter of BOP, produces approximately 50 metric tons annually. The vanilla and cinnamon aroma can be attributed to the volatile cinnamein oils (which contain cinnamates, eugenol and vanillin), a combination of cinnamic acid, benzoyl cinnamate, benzoyl benzoate, benzoic acid and nerodilol.11 Several potential contact allergens exist within MP and can be grouped into the cinnamein oils, benzoic acid derivatives and coniferin derivatives.2

While the MP extract can be found in wound healing preparations and diaper salves, it is not commonly added to cosmetic products,12 rather derivatives (eg, benzyl alcohol) or chemically related cross-reactors may be.13 Because of this, it is considered a marker for perfume allergy.

Unfortunately, for some patients, avoidance of perfume alone may not control their dermatitis (especially when it is systematized) and a low-balsam diet may be warranted.3,14 The low-balsam diet is based on eliminating foods high in MP constituents such as eugenol, cinnamates, vanillin and benzoic acid derivatives, such as citrus fruits, tomatoes and condiments (Table 3).

Hausen et al identified distinct subgroups of allergens in MP and suggested a specific screening series to more accurately identify the allergic component specific to the patient and better guide avoidance2,13,14 (Table 4).

Myroxylon Pereirae Derivatives in Foods

Tomatoes are the most common relevant/provocative food item that triggers flares in MP-sensitized patients.

They contain eugenol, cinnamates, ferulic acid and coniferyl alcohol and should be avoided by patients allergic to these subgroups.15 In the culinary arts, they are used for soup bases, sauces and in condiments, such as ketchup, barbeque and steak sauce.16

Citrus peel from cumquats to grapefruits, limes and oranges may be used in the production of marmalade, candies and garnishes. Citrus peel represents the second most commonly reported food source leading to flare-up dermatitis in MP-sensitized individuals.

It contains cinnamates and ferulic acid.17

Cinnamon is one of the top provocateurs reported by MP-sensitive patients. It specifically contains eugenol, cinnamates and benzoates.17 Cinnamon is used in sweet foods, such as pastries, cereals, candies, cookies, cakes, pies and muffins. Cinnamon is used as a seasoning for savory dishes and meats, and can also be added to teas, boiling chocolate and rum.17

Chocolate contains significant amounts of the MP-derivatives: eugenol, cinnamates and vanillin. It is used as a sweetener, a drink and a glaze for chicken and is an industry in itself.

Cola contains the same MP-derivatives as chocolate (namely eugenol, cinnamates and vanillin) and contains ferulic acid. It is known for its use as a soda beverage, where notably the MP-derivate sodium benzoate is added as a preservative and also as a marinade for meats.17

Cloves are the dried flower buds of Syzygium aromaticum, which contain eugenol and vanillin. They are used in the preparation of curries, marinades, sausage, pies, pickles and cigarettes. Clove oil is also used in synthetic vanilla.17

Vanilla bean and/or extract are commonly used to flavor desserts, in smoothies and teas and as a counterpoint to tomatoes and chili peppers in Latin cuisine.17 Vanilla contains vanillin and benzoic acid.

Sensitization and Testing toMyroxylon Pereirae

The 3 most commonly reported sites of MP-induced dermatitis are the hands, face and anogenital regions.

That said, it has been reported in association with an MP-anti-scabetic ointment8 and leg ulcerations.18 Furthermore, an increasing number of ACD reactions to MP own been seen in infancy and childhood, likely due to an increased use of perfumes and baby care products containing fragrances.19,20

Patch testing for MP allergy can be accomplished with the commercially available patch test device (TRUE Test, Smartpractice USA) or through standard comprehensive testing systems (Allergeaze and Dormer).

Cross-reactions with MP may happen to colophonium (rosin), perfume stir 1, balsam of Tolu, wood and coal tars, resorcin monobenzoate, turpentine, propolis, coniferyl benzoate and benzoin (Table 2).

Occupations at risk for sensitization include dentists (dental cement), bakers (flavoring agents), beekeepers (to beeswax), painters (turpentine), violinist (rosin) and laboratory technicians (fixatives used in the preparation of histology slides).

Practicals of Patch Testing

As discussed, patch testing is often necessary to confirm the diagnosis of ACD and to identify the relevant allergen(s) responsible. Screening patch test trays are available, which isolate the most common chemicals and offer the provider clues for potential sources. The American Contact Dermatitis Society (ACDS) Standard Series includes 80 allergens from several diverse categories,21 additional supplemental trays are also available.22 When it comes to MP, patch testing with the constituents and cross-reactors may increase the chance of demonstrating a relevant positive reaction and permit for more specific avoidance instructions.23

Pearls of Treatment: Every Dose Counts

A person might be exposed to and subsequently sensitized to a contact allergen (eg, a fragrance) for days to years before demonstrating the clinical picture of ACD.

With each exposure, there is an increased risk of reaching a point at which the immune system meets its metaphorical “threshold” and subsequent exposures can lead to elicitation of a cutaneous response.24 Just as repeated contact over time led to this immune response, repeated avoidance of the majority of exposures over time will be required to induce remission.

Avoidance of specific allergens in personal care products can prove to be a tedious task; however, there are programs available to aid in this endeavor.

Both the Contact Allergen Management Program, a service offered through the ACDS,25 and the Contact Allergen Replacement Database, developed by Mayo Clinic,26 permit for a provider to enter a patient’s known contact allergens, and produce a “shopping list” of products void of those specific chemicals. The programs also can exclude cross-reactors. Additionally, education for patients can be accessed through online programs, such as mypatchlink.com27 and through the ACDS website.

Balsam of peru allergy what can i eat

n

Dr. Jacob, the Section Editor of Allergen Focus, is a Pediatric Contact Dermatitis Specialist at Rady Children’s Hospital – UCSD in San Diego, CA.

Disclosure: Dr. Jacob is an investigator for the safety and efficacy trial of the SmartPractice Thin-layer Rapid Use Epicutaneous (TRUE) Test in children and adolescents.

References

1. Bickers DR, Lim HW, Margolis D, et al. The burden of skin diseases: 2004 a joint project of the American Academy of Dermatology and the Society for Investigative Dermatology.

J Am Acad of Dermatol.

Balsam of peru allergy what can i eat

2006;55(3):490-500.

2. Hsu JW, Matiz C, Jacob SE. Nickel allergy: localized, id, and systemic manifestations in children. Pediatr Dermatol. 2011;28(3):276-280.

3. Salam TN, Fowler JF Jr. Balsam-related systemic contact dermatitis. J Am Acad Dermatol. 2001;45(3):377-381.

4. Nijhawen RI, Matiz C, Jacob SE.

Balsam of peru allergy what can i eat

Contact dermatitis: from basics to allergodromes. Pediatric Annals. 2009;38(2):99-108.

5. Militello G, Jacob SE, Crawford GH.

Balsam of peru allergy what can i eat

Allergic contact dermatitis in children. Curr Opin Pediatr. 2006;18(4):385-390.

6. Krob HA, Fleischer AB Jr, D’Agostino R Jr, Haverstock CL, Feldman S. Prevalence and relevance of contact dermatitis allergens: a meta-analysis of 15 years of published T.R.U.E.

Balsam of peru allergy what can i eat

test data. J Am Acad Dermatol. 2004;51(3):349-353.

7. Warshaw EM, Belsito, DV, Taylor JS, et al. North American Contact Dermatitis Group patch test results: 2009 to 2010. Dermatitis. 2013;24(2):50-59.

8. Mögling R. Urticiaria durch Peru balsam. Berl Klin Wschr. 1880;17:557-558.

9. Amado A, Taylor JS. Balsam of Peru or balsam of El Salvador? Contact Dermatitis. 2006;55(2):119.

10. Monardes N. Primera y segunda y tercera partes de la historia medicinal de las cosas que se traen de nuestras Indias occidentales qui sirven en medicinal. Drugs from the West Indies used in Medicine.

Seville, Spain; 1574.

11. Hjorth N. Eczematous allergy to balsams, allied perfumes, and flavoring agents, with special reference to balsam of Peru. Acta Dermatol Venereol Suppl (Stockh). 1961;41(suppl 46):1-216.

12. Api AM. Only Peru Balsam extracts or distillates are used in perfumery. Contact Dermatitis. 2006;54(3):179.

13. Hausen BM, Simatupang T, Bruhn G, Evers P, Koenig WA. Identification of new allergenic constituents and proof of evidence for coniferyl benzoate in Balsam of Peru.

Am J Contact Dermat. 1995;6(4):199-208.

14. Hausen BM. Contact allergy to balsam of Peru. II. Patch test results in 102 patients with selected balsam of Peru constituents. Am J Contact Dermat. 2001;12(2):93-102.

15. Srivastava D, Cohen D. Identification of the constituents of balsam of peru in tomatoes. Dermatitis. 2009;20(2):99-105.

16. Foodfacts.com. http://www.foodfacts.com. Accessed February 25, 2014.

17. Scheman A, Rakowski EM, Chou V, Chhatriwala A, Ross J, Jacob SE. Balsam of Peru: past and future. Dermatitis. 2013;24(4):153-160.

18. Saap L, Fahim S, Arsenault E, et al. Contact sensitivity in patients with leg ulcerations: a North American study.

Arch Dermatol. 2004;140(10):1241-1246.

19. Herro EM, Matiz C, Sullivan K, Hamann C, Jacob SE. Frequency of contact allergens in pediatric patients with atopic dermatitis. J Clin Aesthet Dermatol. 2011;4(11):39-41.

20. Fisher AA. Perfume dermatitis in children sensitized to balsam of Peru in topical agents. Cutis. 1990;45(1):21-23.

21. allergEAZE Allergens website. http://www.allergeaze.com/allergens.aspx?ID=Series. Accessed on February 25, 2014.

22. Patch Test Products 2011. Chemotechnique Diagnostics. 2011. http://www.chemotechnique.se/. Accessed on February 25, 2014.

23. Nijhawan RI, Jacob SE. Patch testing: the whole in addition to the sum of its parts is greatest.

Dermatitis.

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2009;20(1):58-59.

24. Jacob SE, Herro EM, Taylor J. Contact dermatitis: diagnosis and therapy. In: Elzouki AY, Harfi HA, Nazer HM, Bruder Stapleton F, Oh W. Whitley RJ, eds. Textbook of Clinical Pediatrics. 2nd ed. New York, NY: Springer; 2012.

25. ACDS CAMP. American Contact Dermatitis Society website. http://www.contactderm.org/i4a/pages/index.cfm?pageid=3489. Accessed February 25, 2014.

26.

Contact Allergen Replacement Database website. http://www.preventice.com/card/. Accessed February 25, 2014.

27. Balasam of Peru. MyPatchLink website. http://www.mypatchlink.com/pdf/Balsam_Peru.pdf.

Balsam of peru allergy what can i eat

Accessed February 25, 2014.

How to Follow an Anti-Inflammatory Diet for Eczema

As eczema is an inflammatory skin condition, following an anti-inflammatory diet may assist relieve symptoms.

This diet involves eating less of foods that may trigger inflammation in the body, and more of foods that assist fight inflammation. (19)

For this diet, it’s significant to pay shut attention to dietary fats, which can influence the overall quantity of inflammation in the body.

In specific, trans fats, which include hydrogenated oils, some margarine brands, french fries, and other fried foods; and saturated fats, which are found in red meats, full-fat dairy foods, butter, and poultry skin; promote inflammation and therefore may potentially worsen eczema symptoms.

Large quantities of foods wealthy in omega-6 fatty acids, including vegetable oils, may also promote inflammation.

(20)

On the other hand, the three main omega-3 fatty acids — alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) — also own anti-inflammatory properties. EPA and DHA are in fatty fish love salmon, sardines, mackerel, herring, and tuna. Meanwhile, ALA is in flaxseed, canola oil, and soybeans. Other sources of omega-3s include walnuts and green leafy vegetables, love kale, mustard greens, and spinach. (21)

Monounsaturated fats, including olive oil and canola oil, may also be anti-inflammatory.

Aside from these dietary fats, other foods and drinks that may exert anti-inflammatory effects include:

  1. Limit alcohol consumption to one drink per day for women, and two drinks per day for men.

    A standard drink is 14 grams of alcohol, which is about 12 ounces (oz) of beer; 5 oz of wine; 8 oz of malt liquor; or a 1.5 oz shot. (22)

  2. Whole grains (brown rice, quinoa, whole-wheat flour, whole-wheat bread)
  3. Vegetables (spinach, kale, broccoli, onions)
  4. Coffee and tea, especially green tea (contains polyphenols, an antioxidant with an anti-inflammatory effect) (23)
  5. Fruits (cherries, blackberries, strawberries, and blueberries)
  6. Turmeric
  7. Ginger

For an anti-inflammatory diet, make certain to avoid refined carbohydrates and sugar, which may stimulate inflammation.

(24) Refined carbohydrates own had most of their nutritional worth removed. These include white rice, white bread, and white pasta. Also, be on the lookout for hidden sugar. These can be found in cereals, ketchup, and other condiments, sauces, granola bars, and yogurt.

Balsam of Peru, also known and marketed by numerous other names, is a balsam derived from a tree known as Myroxylon balsamum var. pereirae, which is grown in Central America (primarily in El Salvador) and South America.[1]

Balsam of Peru is used in food and drink for flavoring, in perfumes and toiletries for perfume, and in medicine and pharmaceutical items for healing properties.

It has a sweet scent. In some instances, Balsam of Peru is listed on the ingredient label of a product by one of its various names, but it may not be required to be listed by its name by mandatory labeling conventions.

It can cause allergic reactions, with numerous large surveys identifying it as being in the «top five» allergens most commonly causing patch test reactions.[2][3] It may cause inflammation, redness, swelling, soreness, itching, and blisters, including allergic contact dermatitis, stomatitis (inflammation and soreness of the mouth or tongue), cheilitis (inflammation, rash, or painful erosion of the lips, oropharyngealmucosa, or angles of their mouth), pruritus, hand eczema, generalized or resistant plantardermatitis, rhinitis, and conjunctivitis.


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