Allergic Contact Dermatitis from Propolis

Type IV Contact Dermatitis Reactions to Propolis

Although propolis sensitization was originally thought to be most commonly related to occupational exposure, most cases today result from use of propolis-containing products either applied topically (as with cosmetics) or ingested orally.^[53] As shown in Table 2 , the rate of sensitization to propolis among patients suffering from dermatitis has been reported to vary from 1.2 to about 6.6%. Hundreds of cases of contact dermatitis from propolis are now reported from all over the world.^{[2,11,54–61]} In a recent study looking at the frequency of contact sensitization to propolis in children, 5.9% of 1,255 patch-tested subjects reacted positively to propolis (20% in petrolatum [pet]) over an 8-year period. A linear increase in the annual frequency of propolis allergy was seen, possibly reflecting the increase in the use and popularity of propolis-containing products.^[53] Popular products containing propolis include Burt's Bees (Burt's Bees, Inc., Durham, NC), Apivita Propoline products (Apivita S.A., Metamorfossi, Greece), the BeeRich line (Eagle Marketing, Inc., Yukon, OK), ApiHealth products (ApiHealth NZ Ltd., Auckland, New Zealand), P-Bee products (P-Bee Products, Inc., Laguna Hills, CA), and Beehive Botanicals (Beehive Botanicals, Inc., Hayward, WI).

The first report of a case of allergic contact dermatitis from propolis was published in 1915 and described a beekeeper with contact dermatitis on his fingers and wrist.^[62] Since that time, propolis has been recognized as an occupational contact allergen, mainly in beekeepers but also in musicians and people who make stringed musical instruments.^[2,63–69] It is the most common cause of occupational contact allergy in beekeepers and is a much more common sensitizer than beeswax.^[12] For example, a young man aged 23 years was working as a beekeeper when he started having recurrent episodes of eczema on the back of his hands, with swelling of the eyelids and watering of the eyes. These flares occurred at work. A series of patch tests showed positive reactions to balsam of Peru, beeswax, propolis, and extracts of poplar leaves.^[70]

Occupational contact dermatitis may also be caused by airborne propolis emitted from nearby hives.^[69,71,72] Several cases have been reported, and all were related to the patients' being near bee hives. One patient developed repeated redness, swelling, and itching in the periorbital regions after he opened the beehives and removed the honey. Skin contact with honey and dead bees was tolerated, and no hand dermatitis was present. Patch-test reactions to propolis, allergen LB-1, and balsam of Peru were all positive, suggesting that the patient was reacting to an "odorous cloud" that was emitted from the hives, and his symptoms resolved upon avoidance.^[71] A similar case was seen in a 57-year-old beekeeper who had repeated episodes of erythema and facial itching and swelling after collecting honey but who also never developed hand dermatitis. He had positive patch-test reactions to honey, wax, and propolis.^[69]

In addition to cases related to beekeeping, several other cases of occupational propolis allergy have been described. Henschel and colleagues described a 50-year-old man with a 1-year history of hand dermatitis who worked in a retail store, handling everything from raw materials to manufactured goods, including untreated and finished wood products. Patch tests with the European Standard, facial, preservatives, rubber, and office worker series including propolis revealed a single ++ reaction to 10% propolis at 2 and 4 days. Wearing gloves at work improved his symptoms.^[64] A positive reaction to propolis was also seen in a shoemaker with vesicular hand eczema who used beeswax in making shoes.^[65]

Aside from the typical presentation of an erythematous vesiculopapular eczema, contact dermatitis from propolis can also result in some unusual clinical presentations. Two cases of propolis contact dermatitis presented in a setting of psoriasis. These patients applied a cream that contained propolis to their arms and/or active areas of psoriasis, resulting in exacerbation of the disease. Patch tests showed positive reactions to propolis.^[73] Propolis-induced contact dermatitis can also mimic pemphigus vulgaris, which was the case in a patient who applied propolis-containing ointment and lip balm, resulting in blistering dermatitis of the lips and adjacent oral mucosa, leading to an initial misdiagnosis of pemphigus.^[74] Another patient had treated an abrasion below the nose with a lotion containing 20% propolis. After a week, a papule appeared that later developed into an erythematous nodule, accompanied by fever and enlarged lymph nodes in the submental, submaxillary, and cervical regions. Antibiotics had little effect, and a skin biopsy specimen showed epidermal hyperplasia and granuloma formation. Cultures were negative, and patch testing with the propolis lotion resulted in a positive reaction. The lesion healed, and the lymphadenopathy resolved after topical application of the propolis solution was discontinued.^[75]