H20 Gin or tonic: the dermatological hazards of cocktail-based quinine

Abstract

Abstract Derived from Cinchona tree bark, quinine was first found to be beneficial to health by indigenous Amazonian peoples. Seventeenth-century Jesuit missionaries sent the bark and seeds back to Europe, where word of its therapeutic properties spread. Quinine was promoted as an antiseptic treatment for a range of ailments from the 1600s onward, including septicaemia, erysipelas and scarlet fever. The dermatological risks of quinine quickly became recognized, with Bartholow stating in his 1876 work that ‘The action of quinia has occasionally been attended by the appearance of an eruption on the skin. Sometimes the exanthem has been in the form of an erythema, sometimes it has assumed the appearance of urticaria.’ The pharmacological properties of quinine were exploited by colonial institutions such as the East India Company, who combined a pragmatic approach to antimalarial prophylaxis with a British penchant for aperitivos. The bitter taste of quinine in tonic water led to the addition of water, sugar, lime and gin, giving rise to the gin and tonic (G&T). Its enduring popularity is, in part, due to the astringent nature of quinine and its acidic content that acts as a ‘stomachic tonic; that is, promote appetite, the flow of gastric juice, and the digestive power’. However, since its advent, the G&T has been attributed to many cases of dermatological malaise, as discovered by this systemic review of the published PubMed and SCOPUS literature. To the adage ‘new drugs, new eruptions’, the G&T was no exception. The first published skin reaction to quinine in tonic water dates from 1955, occurring shortly after the patient attended a cocktail party after which they developed ‘a burning sensation in the groins and in his hands and feet’ with progressive oedema and erythema to these areas, spreading to involve nearly all of the body. Other published cases describe (in decreasing frequency) fixed drug eruptions, photosensitive reactions, allergic urticaria and lichenoid drug reactions triggered by quinine in G&Ts. The spectrum of eruptions triggered by tonic water extends to Stevens–Johnson syndrome/toxic epidermal necrolysis triggered by scotch and tonic water consumed at the patient’s peril during a convention in 1972. With an enduring popularity spanning two centuries, and a declaration from Churchill that ‘the gin and tonic has saved more Englishmen's lives, and minds, than all the doctors in the Empire,’ it is vital that dermatologists are aware of the potential dermatological hazards of the G&T.