Fragrance as an occupational

allergen
D. A. Buckley, R. J. G. Rycroft, I. R. White and J. P. McFadden
St John’s Institute of Dermatology, St Thomas’ Hospital, London SEI 7EH, UK

Sensitization to fragrance is believed to occur mainly outside the workplace. This

study addresses the frequency of fragrance allergy in patch test patients of differing
occupations during a 15 year period. The occupation most strongly associated with
fragrance allergy in both sexes was health care work (positive tests in 11.7% of
males and 10.4% of females). Retired individuals also had high rates of fragrance
allergy (11.6% of males and 14.5% of females), and the prevalence of sensitization
increased with advancing age. Health care workers and metalworkers had statistically
significantly higher rates of allergy to eugenol than did workers in other occupations.
Food handlers had significantly higher rates of allergy to cinnamal and cinnamic
alcohol. These findings suggest that sensitization to fragrance occurs more frequently
in an occupational setting than is generally understood and could have implications
for preventive measures.
Key words: Allergic contact dermatitis; cinnamal; cinnamic alcohol; eugenol;
fragrances; isoeugenol; oak moss; occupation; patch testing; perfumes.

Received 18 September 2000; revised 22 October 2001; accepted 12 November 2001

Introduction Subjects and methods

Sensitization to fragrance is believed to occur mainly in a All patients referred to us are tested with a standard
non-occupational setting, such as following the use of screening series of 35–40 allergens, including the Hermal
scented cosmetics [1]. Although the most frequent fragrance mix (8% in petrolatum). We use a computerized
primary site of dermatitis in fragrance-allergic patients is database to record for each patient at the time of patch
the hands [1–3], this may reflect the diminished barrier testing their age, sex, primary site of dermatitis, stated
function of skin exposed to irritants in the workplace current occupation, whether any extra series are tested
or home, which allows penetration and sensitization by and what positive reactions are found. Where possible,
fragrance. The hands encounter many scented household patients judged from their history to be fragrance allergic
products daily, and are used to apply cosmetics and or who have positive reactions to the fragrance mix at the
perfumed medicaments to other body sites.
Occupational allergic contact dermatitis to fragrance
has been reported in hairdressers, aromatherapists,
workers in the fragrance and cosmetic manufacturing Table 1. Constituents of the 8% fragrance mix
industries, bakers and confectioners, and coal miners
Test concentration
from use of a fragranced body lotion [1,2,4]. We were INCIa name (% in petrolatum)
interested to know whether any particular occupations
were a risk factor for fragrance allergy in our patients Oak moss 1
and whether any individual fragrance chemicals were Isoeugenol 1
associated with certain types of work. We report here the Eugenol 1
frequency of fragrance allergy in patch test patients of Cinnamal 1
Cinnamic alcohol 1
different occupations during a 15 year period. Alpha-amyl cinnamal 1
Geraniol 1
Hydroxycitronellal 1
Sorbitan sesquioleateb 5

Correspondence to: Dr D. A. Buckley, Department of Dermatology, a

INCI = International Nomenclature of Cosmetic Ingredients.
Princess Margaret Hospital, Swindon, Wiltshire SN1 4JU, UK. Tel: +44
b
1793 426624; fax: +44 1793 437053; e-mail: dbuckley@doctors.org.uk Sorbitan sesquioleate is an emulsifier.

Occup. Med. Vol. 52 No. 1, pp. 13–16, 2002

Copyright © Society of Occupational Medicine. Printed in Great Britain. All rights reserved. 0962-7480/02
14 Occup. Med. Vol. 52, 2002

first reading are additionally tested with the constituents
of the fragrance mix (Table 1). The patient’s occupational
group is recorded according to the categories listed in
Table 2. Health care workers include doctors, dentists,
veterinarians and nurses.
The number of patients from each occupation with
positive reactions to the fragrance mix between 1 January
1984 and 31 December 1998 was obtained retrospect-
ively from the database. The total number of patients
patch tested belonging to each occupational group was
then used to make a calculation of the percentage of
patients in each occupation with positive reactions to
the fragrance mix (Table 2). As the number of positive
reactions to the fragrance mix in some occupational
groups was small and might give misleading results,
we considered noteworthy only results for groups in
which >15 individuals were fragrance allergic. Significant
associations between allergy to constituents of the fra-
grance mix and particular occupations were also sought.
The χ2 or Fisher’s exact test statistics were used in the
analysis as far as the sample sizes involved in group
comparison would allow.

Table 2. Percentage of individuals in each occupational group allergic to the fragrance mix, 1984–1998

Females Males

No. allergic to No. allergic to

Occupation No. tested fragrance mix % positive No. tested fragrance mix % positive

Carpenter 8 2 25 120 8 6.7

Retired 885 128 14.5 1017 118 11.6
Service industry worker 118 13 11.0 285 20 7.0
Storekeeper 65 7 10.8 127 9 7.1
Health care 779 81 10.4 154 18 11.7
Florist 119 12 10.1 107 7 6.5
Teacher 370 37 10.0 119 6 5.0
Phototechnician 31 3 9.7 74 2 2.7
Metalworker 83 8 9.6 741 39 5.3
Money handler 183 17 9.3 21 0 0
Office worker 3958 366 9.2 1475 124 8.4
Salesperson 397 36 9.1 211 15 7.1
Plastic handler 44 4 9.1 141 3 2.1
Military 11 1 9.1 68 4 5.9
Food handler 66 6 9.1 96 10 10.4
Housewife 2336 208 8.9 46 2 4.3
Paramedic 217 18 8.8 49 0 0
Performer 102 9 8.8 51 3 5.9
Arts and crafts 128 11 8.6 94 3 3.2
Other 214 16 7.5 305 13 4.3
Printer 40 3 7.5 191 7 3.7
Supervisor 58 4 6.9 72 9 12.7
Electrician/plumber 16 1 6.3 277 18 6.5
Scientist 195 12 6.2 153 7 4.6
Caterer 603 36 6.0 410 26 6.3
Mechanic 17 1 5.9 505 13 2.6
Paper handler 35 2 5.7 93 8 8.6
Hair/beauty worker 437 25 5.7 50 5 10.0
Transport worker 54 3 5.6 346 21 5.1
Assembler 89 5 5.6 39 2 5.1
Domestic worker 397 22 5.5 114 4 3.5
Unemployed 567 29 5.1 640 23 3.6
Textile handler 121 6 5.0 42 4 9.5
Student 1172 41 3.5 590 16 2.7
Construction worker 10 0 0 356 24 6.7
Engineer 15 0 0 149 12 8.1
Painter 10 0 0 101 7 6.9
Chemical handler 34 0 0 165 5 3.0
Rubber worker 11 0 0 37 0 0
Electroplater 3 0 0 17 0 0

Total 14 052 1177 8.5 9994 636 6.4

 D. A. Buckley et al.: Fragrance as an occupational allergen 15

Results 44.2 years. The mean age of fragrance-allergic retired

In total, 24 046 patients (14 052 females, 9994 males)
were tested. Of these, 1813 had positive patch reactions
to the fragrance mix and 1112 were tested with its
constituents. Positive patch test reactions to the fragrance
mix occurred in 6.4% of males (n = 636) and 8.5% of
females (n = 1177). Fragrance allergy was most common
in retired individuals, being present in 118 of 1017 males
(11.6%) and 128 of 885 females (14.5%), and in health
care workers, being present in 18 of 154 males (11.7%)
and 81 of 779 females (10.4%). Students had low rates of
sensitization for both sexes: 16 of 590 males (2.7%) and
41 of 1172 females (3.5%). The rate in housewives was
similar to that in the entire female patch test population
(208 of 2336; 8.9%).
The most commonly affected body site in fragrance-
allergic health care workers was the hands, which were
affected in 31 of 81 females (38.3%) and 5 of 18 males
(27.8%). The hands were affected in 30.3% of house-
wives, 16.7% of retired individuals and 14% of students,
respectively. Overall, the hands were the primarily
affected site in 27.9% of fragrance-allergic patients. Con-
versely, the face and neck was the most common site
of dermatitis in the retired [31 of 127 (24.4%) females
and 24 of 119 (20.2%) males] and in students [16 of 41
(39%) females and 3 of 16 (18.8%) males]. The face
and neck was affected in 45 of 209 (21.5%) housewives
and 18 of 99 (18.1%) health care workers. Overall, the
face and neck was the site of dermatitis in 23.6% of
fragrance-allergic patients.
The mean age of all fragrance-allergic patients was
individuals was 69.3 years and of students 21.3 years. The
prevalence rates of fragrance allergy increased with age:
from only 2.8% of those tested aged 0–9 years to a peak of
14.4% in females aged 60–69 years and 13.7% in males
aged 70–79 years. In female health care workers, the rate
of allergy to fragrance showed a steady increase: from
9.6% of those in their twenties to 23.5% of those in their
sixties. The rate of fragrance allergy in retired individuals
peaked in those in their seventies at 15.9% of females and
14.2% of males, declining thereafter.
Positive reactions to at least one fragrance mix constitu-
ent occurred in 934 patients (609 females, 325 males),
most commonly to oak moss (n = 378) and isoeugenol
(n = 231) (Table 3). The majority of these patients (826;
532 females, 294 males) had already been identified as
fragrance allergic by reacting to the fragrance mix. In
patients allergic to a fragrance mix constituent, 14 of 55
health care workers (25.5%) were allergic to eugenol
versus 145 of 879 non-health care workers (16.5%;
P = 0.03). Eleven of 29 metalworkers (39.3%) were
allergic to eugenol versus 148 of 906 in other occupations
(16.3%; P = 0.004). Eight of 13 food handlers were
allergic to cinnamal and/or cinnamic alcohol (61.5%)
versus 242 of 921 in other occupations (26.3%; P =
0.007). An additional six food handlers who were negative
to the fragrance mix constituents had positive reactions to
balsam of Peru. Fifteen of 28 students were allergic to
isoeugenol (53.6%) versus 216 of 906 in other occupa-
tions (23.8%; P = 0.0006). There was no other significant
link between occupational group and allergy to individual
fragrance chemicals.

Table 3. Number of patients in different occupations with positive patch tests to a fragrance mix constituent

Cinna Cinn alca Oak moss Isoeugena Eugenol Hydroxya Geraniol A-amyl-ca Sorb Sesa All consa

Office worker 52 27 118 61 38 24 19 11 14 267

Housewifeb 27 18 49 17 16 11 12 3 4 112
Retired 25 17 33 21 16 7 8 5 4 92
Health care 9 5 24 14 14 6 2 1 1 55
Caterer 9 6 6 12 6 3 1 0 0 31
Student 2 2 9 15 5 5 3 2 3 28
Metalworker 3 6 10 7 11 0 0 0 1 28
Salesperson 5 5 15 6 4 2 1 2 1 26
Unemployed 2 2 6 4 5 6 5 1 1 24
Hairdresser 3 4 9 2 1 2 3 0 0 20
Service worker 1 2 10 6 7 3 0 0 1 19
Teacher 5 2 8 4 3 2 1 1 0 18
Transport worker 5 6 4 6 2 0 0 0 0 17
Builder 5 2 6 5 3 3 3 1 0 16
Food handler 6 6 3 3 1 0 3 0 0 13
Other 36 29 68 48 27 15 6 4 5 168
Total 195 139 378 231 159 89 67 31 35 934

a
Cinn, cinnamal; Cinn alc, cinnamic alcohol; Isoeugen, isoeugenol; Hydroxy, hydroxycitronellal; A-amyl-c, alpha-amyl-cinnamal; Sorb Ses, sorbitan sesquioleate;
All cons, all constituents.
b
All female.
16 Occup. Med. Vol. 52, 2002
Discussion
Our data show that health care workers have an increased
risk of fragrance allergy, supporting the concept of rele-
vant occupational exposure in these professions. Nurses,
doctors, dentists and veterinarians are required to wash
their hands regularly to combat the spread of infection.
Soaps, antiseptic solutions and emollient creams are
frequently perfumed. Nurses bathe and apply emollients
and medicaments to patients, exposing themselves
further to fragrance chemicals. A previous study showed
a higher relative risk of allergy to the fragrance mix in
nurses and massage therapists [5]. Dentists are exposed
to eugenol in mouthwashes, dressings, impression mat-
erials and periodontal packings, which may account for
the increased likelihood of allergy to eugenol we have
demonstrated in health care workers [6,7]. The higher
rate of allergy to eugenol in metalworkers suggests its
common presence in cutting fluids, but there are no
published data to confirm this. However, eugenol is
present in 27% of household products [8].
Food handlers encounter spices and essential oils,
which contain natural fragrance allergens such as cin-
namal, cinnamic alcohol and balsam of Peru. Cinnamal
and cinnamic alcohol are cross-reacting related perfume
chemicals. Both are found in balsam of Peru, cinnamon
leaves and cinnamon oil, among other spices. Occupa-
tional contact allergy to spices with associated fragrance
allergy is well recognized [9]. Cinnamal and cinnamic
alcohol are less frequently included in commercial per-
fumes than in the past, due to their sensitizing potential,
so that during the last two decades in our clinic the overall
frequency of sensitization to these chemicals has declined
[10].
In this study, retired individuals had the overall highest
risk of fragrance allergy. This may reflect the older age of
retired patients, as we found the prevalence of fragrance
allergy in both sexes to increase with advancing age before
falling off in the last 1–2 decades of life. This increase
in fragrance allergy with advancing age was exaggerated
in health care workers, suggesting that factors within
the workplace contributed to sensitization. Increasing
cumulative exposure to potentially sensitizing fragrance
chemicals in the home and work environments over time
is likely to be the cause of this age-related increase in
fragrance allergy. It is counterbalanced in the later years of
life by the fact that both the elicitation and induction of
allergic contact dermatitis decline with increasing age
[11]. The low prevalence of fragrance allergy in students
may reflect their younger age and less cumulative
exposure. The predominance of isoeugenol allergy in
students reacting to a fragrance mix constituent suggests
non-occupational sensitization from deodorants and cos-
metics, in which isoeugenol may be present at significant
concentrations [12].
Fragrances and cosmetics accounted for 8% of cases of
occupational allergic contact dermatitis reported by UK
dermatologists between 1993 and 1999, affecting hair-
dressers, beauticians, machine tool operators (metalwork-
ers), nurses, food workers and cleaners [13]. Irrespective
of workplace exposure, almost all fragrance-mix-sensitive
patients have additional non-occupational exposure, and
the contribution of scented products encountered in the
workplace may be difficult to assess. Since 1973, the
International Fragrance Association has set regularly
updated advisory limits on the nature and concentration
of sensitizing fragrance chemicals to be added to cos-
metics. It would be helpful if similar limits could be set for
industry and for household chemicals such as washing-up
liquid. In an ideal world, all products encountered by
health care professionals in their daily work should be
fragrance free.
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