Severe allergic skin reaction after use of red tiger balm

Abstract

The red tiger balm is an old product. It is available since more than 100 years and is distributed in more than 100 countries. The application of red tiger balm induces local warmth. In normal use, 3 to 4 daily applications are recommended by the seller. It is used for muscular pain and back pain. It is composed by: petrolatum, syntetic wax, camphor, menthol, melaleuca leucadendron cajaputi oil, mentha benzyl alcohol, arvensis oil, eugenia caryophyllus flower oil, cinnamal, eugenol, limonene, coumarin, linalool, isoeugenol, cinnamyl acohol. No major side effect of topical use was previously described. A 50 years woman applied tiger balm on her left knee for the first time for arthralgia. She also took 400 mg of ketoprofen. She immediately felt burning sensation and tingling on the application zone, on contralateral knee in contact and on the both hands. She washed it immediately but an erythema appeared rapidly, followed by bullous eruption only on knees. Two day after, she consulted at the emergency department, the physician reported grade 2 burning like lesions with erythema, pruritus and bullous eruption on the both knee and an contact eczema on both hands. The physician called the local poison center to report the case. Pictures of the lesion were made for the first time at the emergency department. For treatment, she needed steroid local treatment and daily nursing. Symptoms were present during 7 days. She was healed after 16 days. A scar is still remaining but she does not have any movement restriction. She had no medical history except an allergy to hymenoptera and caterpillars. She didn’t take any treatment. Complementary allergic tests were performed 35 days after the event. Allergies to linalool and limonene were found. We report the first case of major allergic skin manifestations following the application of red tiger balm. In this compound, only camphor, that induces local warmth, is recorded as deadly toxic. Cutaneous inflammatory effects after tiger balm application were recorded after 21 days of application on rabbits. No immediate skin inflammation was described in the literature. The common manifestation of allergic skin reaction is a local inflammation with pruritus but rarely a bullous eruption. We don’t know the origin of the sensitization before this reaction. In this case of allergic reaction, they are 2 suspected compounds. The linalool which produces linalool oxides in contact with oxygene (hydroperoxides, furanoxides, pyranoxides, alcohols and linalyl aldehyde), and are described to induce skin sensitization [1] . The limonene, which is an aromatic component present in food and drink for lemon-like odor was also described to induce skin sensitization [2] . They are no record of major allergic effect with any of these components individualized or associated. Both linalool and limonene were recorded as component of tiger balm. This case was reported to cosmetovigilance.