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Kasuistik Allergologie, Jahrgang 33, Nr. 9/2010, S.

Case report
Contact dermatitis of the lips due to late-type
sensitization against dalbergiones in a
wooden recorder
C. Pföhler and W. Tilgen

Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des

Saarlandes, Homburg/Saar

Key words Contact dermatitis of the lips due to Allergische Kontaktdermatitis der
dalbergiones – record- late-type sensitization against dalbergio- Lippe bei Typ-IV-Sensibilisierung ge-
er – contact dermati- nes in a wooden recorder genüber Dalbergionen in Flötenholz
tis – (S)-4’-hydroxy-4- Background: Late-type sensitizations Hintergrund: Typ-IV-Sensibilisierungen
metho- xydalbergione against wood are rare and are mostly seen in gegenüber Hölzern sind selten und werden
– (S)-4-methoxydalber- patients with occupational contact with saw meist bei Personen gefunden, die berufli-
gione dust. Generally, commercial wooden prod- chen Umgang mit Holzstäuben haben. Fer-
ucts only lead to sensitization or dermatitis tige Holzprodukte führen in der Regel nur
Schlüsselwörter in cases when contact to the unprotected skin dann zu einer Sensibilisierung bzw. Derma-
Dalbergione – Flöte – is direct, intensive and of longer duration, titis, wenn der Hautkontakt direkt, intensiv
Grenadil – Kontaktder- i.e. by wearing wooden jewelry or by play- und langzeitig ist, zum Beispiel beim Tra-
matitis – (S)-4’-hydroxy- ing wooden instruments. Causative for the gen von Holzschmuck und beim Musizie-
4-methoxydalbergion sensitization process are ingredients of the ren auf Holzinstrumenten. Ursächlich für die
– (S)-4-methoxydalber- wood core such as alkaloids, glycosides, an- Sensibilisierung vom Spättyp sind Inhaltsst-
gion thrachinones, saponines, phenols, catechols, offe des Kernholzes wie Alkaloide, Glyko-
flavonoids, cumarins, and benzo-, naphtho-, side, Anthrachinone, Saponine, Phenole,
furano-, and phenanthrenquinones and their Katechole, Flavonoide, Kumarine und Ben-
precursors. Case report: We report the case zo-, Naphtho-, Furano- und Phenanthrenchi-
Received for publication of a 70-year-old patient who developed chei- none bzw. deren Vorstufen. Fallbericht: Wir
January 13, 2010 litis after playing different wooden recorders berichten über einen 70 Jahre alten Patient-
made of African blackwood, rosewood, ce- en, bei dem sich nach Musizieren auf Flöten
Peer reviewed dar, olive, and pear. Methods: Patch testing mit verschiedenen hölzernen Mundstück-
with baseline series of contact allergens and en aus Grenadil, Palisander, Zedern-, Oliv-
Accepted for publication saw dust of the recorders were performed as en- und Birnenholz wiederholt eine Cheilitis
June 1, 2010 well as skin prick tests with common inhal- entwickelte. Methodik: Es erfolgte eine Epi-
ant allergens and saw dust of the recorders. kutantestung mit der Standardreihe und mit
Results: Patch testing showed sensitizations Holzstaub der Flöten sowie eine Prick-Tes-
against African blackwood, rosewood, fra- tung mit verbreiteten Inhalationsallergenen
grance mix 2 and hydroxyisohexyl-3-cyclo- und mit Holzstaub der Flöten. Ergebnisse:
hexene carboxaldehyde. Skin prick testing Die Epikutantestung ergab Typ-IV-Sensi-
was without pathological results. Conclu- bilisierungen gegenüber Grenadil und Pal-
sion: African blackwood and rosewood con- isander sowie gegenüber Duftstoffmix 2 und
tain (S)-4’-hydroxy-4-methoxydalbergione Hydroxyisohexyl-3-cyclohexen-Carbox-
and (S)-4-methoxydalbergione. As a result of aldehyd. Die Prick-Testung war unauffäl-
the chemical affinity between the dalbergio- lig. Schlussfolgerungen: In Grenadil und
nes, cross-reactions between different woods Palisander sind die Dalbergione (S)-4’-hy-
are observed. The case presented shall show droxy-4-methoxydalbergion und (S)-4-me-
the diagnostic procedure in cases in which thoxydalbergion enthalten. Aufgrund der
sensitizations against wood components are chemischen Ähnlichkeit der Dalbergione un-
suspected. tereinander können Kreuzreaktionen zwisch-
en verschiedenen Hölzern, wie bei unser-
em Patienten auf Grenadil und Palisander,
beobachtet werden. Der vorgestellte Fall soll
das diagnostische Prozedere bei Verdacht auf
© 2010
Dustri-Verlag Dr. Karl Feistle
eine Sensibilisierung gegenüber Holzbes-
ISSN 0344-5062 tandteilen aufzeigen.
Contact dermatitis of the lips due to late-type sensitization against dalbergiones in a wooden recorder 411

We carried out patch tests using the stan-
dard allergens (Almirall Hermal, Reinbek,
Germany) and saw dust from the mouth-
pieces of his recorders (10% in petrolatum).
The allergens were applied on his upper back
using Finn Chambers® on Scanpor (Epitest,
Tuusula, Finland) and attached with Fixo-
mull Stretch Tape (BSN Medical, Hamburg,
Germany). The allergens were removed 24
hours later to avoid irritant reactions. The
test results were checked after 24, 48 and 72
hours according to the guidelines published
by the International Dermatitis Research
Group (ICDRG).
Inhalable allergens (grass pollen mix,
Figure 1.  Erosive cheilitis 24 hours after playing a
recorder made of African blackwood. Patient’s re-
tree pollen mix, mugwort, Dermatophagoi-
corders (inset): A: rosewood; B: African blackwood; des pteronyssinus, Dermatophagoides fa-
C: olive; D: pear; E: cedar. rinae and feathers) were tested in a routine
prick test using commercially available test
solutions (Bencard, Munich, Germany). Fur-
thermore a skin prick test with saw dust from
Introduction the different mouthpieces of his recorders
Dalbergia melanoxylon is also known (1% in water) was carried out. The results
as African Blackwood and native to Africa, of this skin prick test were checked after 20
mainly Tanzania and Mozambique. The minutes and after 24 hours. The patch testing
dense heart wood is of a purple-blackish col- and the prick testing were also carried out in
or with black stripes and can be mistaken for 7 control persons who had presented to our
ebony. Due to its nice color and to its hard- hospital for diagnostic work-up of occupa-
ness it is frequently used for wooden instru- tion-related sensitizations. These control
ments like clarinets, oboes and recorders, but persons were informed about the aim of the
also for chess pieces and combs [2, 4]. testing and about the possibility of an active
sensitization and gave their written consent
to the additional testing.
Case report
A 70-year-old patient presented to our Results
allergology department with a 2-year his-
The patch testing showed positive reac-
tory of relapsing erosive cheilitis (Figure
tions to African blackwood and rosewood
1). The changes in the skin had always been
(Figure 2) as well as to fragrance mix 2 and
treated with low-potency topical corticoste-
roids which had always resulted in a remis-
dehyde (Lyral). The sensitization to the fra-
sion within several days. The specific patient
grance mix was clinically irrelevant accord-
history revealed that the patient had been
ing to the patient history. Skin prick testing
playing different types of recorders with
was without pathological results. The tested
mouthpieces made of African blackwood,
control persons did not show any abnormali-
rosewood, cedar, olive or pear in his leisure
ties in the patch and prick tests.
time (Figure 1, inset). He had already sus-
pected an association between his hobby and
the episodes of cheilitis, but was not sure Discussion
which of the mouthpieces had caused the le-
sions. When using a plastic mouthpiece the Dalbergia melanoxylon or African black-
condition did not occur. wood is a tropical hardwood that can easily
Pföhler and Tilgen 412

The case presented here is supposed to

remind dermatologists of the fact that, in
rare cases, wooden instruments can cause
contact allergic skin reactions. When sensi-
tization to certain woods is suspected, patch
and prick tests with alcohol or water extracts
of the suspected woods should be carried out
[2, 5]. As these extracts are usually not com-
mercially available, patch testing can be car-
ried out with an individually produced test
formulation (10% saw dust in petrolatum). It
has to be noted that for several woods, like
teak, this concentration might be too high
and could cause irritant reactions or active
sensitizations [2]. In such cases a titration
series should be used.

Conflict of interest
Figure 2.  Positive patch test reactions to African None.
blackwood (A) and rosewood (B) after 48 hours.

be mistaken for ebony (Diospyros species) [1] Chieregato C, Vincenzi C, Guerra L, Rapacchiale
due to its color. The heart wood is very hard S. Occupational airborne contact dermatitis from
and dense and is used for the production of Machaerium scleroxylon (Santos rosewood).
Contact Dermat. 1993; 29: 164-165.
wooden recorders due to its nice color as
[2] Fuchs T, Aberer W. Kontaktekzem. 2. Auflage.
well as its temperature and moisture resis-
München – Orlando: Dustri; 2007.
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asthma-like symptoms are usually only ob- er und allergischer Kontaktdermatitiden durch
served in persons with occupational contact Machaerium scleroxylon Tul. (Pao ferro), einem
Ersatzholz für Palisander (Dalbergia nigra All.).
to tropical woods and their saw dusts (saw-
Hautarzt. 1982; 33: 321-328.
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rarely they arise due to contact with wooden bracelet and a recorder]. Derm Beruf Umwelt.
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“fiddler’s neck”, or due to skin contact with [6] Rackett SC, Zug KA. Contact dermatitis to mul-
jewelry like bracelets or necklaces made of tiple exotic woods. Am J Contact Dermat. 1997;
8: 114-117.
tropical wood [1, 3, 5].
[7] Stingeni L, Proietti G, Zeppa L, Lisi P. Occupa-
The reason for allergic reactions after tional airborne contact dermatitis from Machae-
contact with African blackwood are, like rium scleroxylon: A simple method for extracting
in the case of other Dalbergia species, the quinones from wood. Contact Dermatitis. 2008;
quinones (S)-4’-hydroxy-4-methoxydalber- 58: 117-118.
gione and (S)-4-methoxydalbergion. As a
result of the structural similarity of all dal- PD Dr. med. Claudia Pföhler
bergiones cross-reactions between different Klinik für Dermatologie,
Venerologie und Allergologie
woods are observed [7]. This was also the
Universitätsklinikum des Saarlandes
case in our patient who had positive patch Kirrbergerstraße 100
test reactions to African blackwood and rose- D–66421 Homburg/Saar
wood. e-mail: