You are in: eMedicine Specialties > Dermatology > PHOTO-RELATED DISEASES Berloque DermatitisArticle Last Updated: Jun 2, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Ali Alikhan, BS, University of California, Davis School of Medicine Ali Alikhan is a member of the following medical societies: American Medical Student Association/Foundation, Islamic Medical Association of North America, and Student National Medical Association Coauthor(s): Ai-Lean Chew, MBChB, Specialist Registrar, Department of Dermatology, St John's Institute of Dermatology, UK; Howard I Maibach, MD, Professor and Vice Chairperson, Department of Dermatology, University of California School of Medicine at San Francisco; Consulting Staff, University of California Hospitals Editors: Marjan Garmyn, MD, PhD, Professor, Faculty of Medicine, Katholieke Universiteit Leuven, Belgium; Chair and Adjunct Head, Department of Dermatology, University of Leuven, Belgium; David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic; Edward F Chan, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System Author and Editor Disclosure Synonyms and related keywords: berlock dermatitis, perfume phototoxicity, perfume photoirritation, bergapten phototoxicity, bergapten photoirritation, bergamot phototoxicity, bergamot photoirritation, photodermatitis pigmentaria, dermite pigmentée en forme de coulée, 5-Methoxypsoralens photoirritation INTRODUCTIONSection 2 of 9
  BackgroundBerloque dermatitis obtains its name from the German word berlock or the French berloque, meaning trinket or charm. Rosenthal1 coined the term in 1925 to describe pendantlike streaks of pigmentation on the neck, face, arms, or trunk. He suspected they were due to fluid droplets, unaware that Freund2 in 1916 had described hyperpigmented macules due to sun exposure after the application of eau de cologne. The phototoxic ingredient causing the pigmentation proved to be bergapten, a component of oil of bergamot, derived from the rind of Citrus bergamia, the bergamot lime. Several cases were reported in the 1950s and 1960s following increased use of perfumes containing oil of bergamot and the passion for sunbathing. Since the introduction of artificial oil of bergamot and the reduced use of the natural product in perfumes, berloque dermatitis has become rare.
PathophysiologyPhototoxicity or photoirritation is a chemically induced nonimmunologic acute skin irritation requiring light (usually within the UVA spectrum, ie, 320-400 nm). The skin response resembles exaggerated sunburn and does not require prior sensitization; it can be caused by a single simultaneous exposure to the chemical and light source. The photoactive chemical may enter the skin via topical administration, or via ingestion, inhalation, or parenteral administration. The reaction can be evoked in all subjects as long as the concentration of the chemical and the dose of light are sufficient. In the case of berloque dermatitis, the phototoxic reaction is induced by the effect of long-wave ultraviolet (UVA) radiation on bergapten, or 5-methoxypsoralens, a furocoumarin now known to be the only photoactive component of bergamot oil (see Media File 2). The bergapten-UVA radiation combination induces an intensification of melanogenesis and a corresponding increase in the number of functional melanocytes, which are more dendritic and dopa-positive. The distribution of melanosomes in keratinocyte changes from the aggregate to nonaggregate form. FrequencyUnited StatesThe exact incidence of berloque dermatitis is unknown. In the Untied States, berloque dermatitis now is exceedingly rare due to the use of bergapten-free fragrance formulations. The US Hazardous Substances Act issued regulations stating that products containing oil of bergamot must not exceed 62 ppm bergapten, 2% bergamot oil. Following work performed by Marzulli and Maibach3 and reported in 1970, even lower concentrations than this have been recommended (<0.3% bergamot oil, equivalent to 0.001% bergapten), and bergapten-free bergamot oil is used almost always now in the Untied States. However, in some countries where bergamot oil continues to be used, berloque dermatitis remains a problem. Even in the Untied States, milder forms still are being observed. Recently, a patient was reported to have severe berloque dermatitis due to using a suntan booth immediately after applying some 40-year-old Shalimar perfume, which contained bergamot oil. Apart from the bergamot lime, bergapten also is a component in other substances, inducing bergapten phototoxicity without the typical pendantlike appearance of berloque dermatitis. For instance, in Norway, bergapten phototoxicity has been reported due to Heracleum laciniatum and in Denmark due to Heracleum mantegazzianum (giant hogweed).4, 5 Mortality/MorbidityPhototoxic reactions currently are the most frequently recognized form of photosensitivity reactions. Berloque dermatitis, however, is far more uncommon due to the reasons described above. RacePrecise information about racial predilection is not available. SexBerloque dermatitis usually occurs in females who wear fragrances containing oil of bergamot, but males who wear fragrances or fragrance-containing products, such as aftershave lotion, also may develop berloque dermatitis. AgeBerloque dermatitis usually occurs in women, although it can occur in persons of any age who apply fragrances containing oil of bergamot. CLINICALSection 3 of 9
HistoryThe clinical presentation of berloque dermatitis may be classically divided into 2 phases. The initial acute inflammatory phase consists of erythema, edema, pain, pruritus, and increase in skin temperature around the area of contact with the phototoxic agent. The second stage is hyperpigmentation of the lesion. Patients usually present with small areas of redness or pigmentation of the skin, usually on sun-exposed areas, such as the neck. Pain and, sometimes, pruritus may be felt during the acute erythematous phase before the lesions become hyperpigmented. However, hyperpigmentation is the chief complaint; sometimes patients may not even recall the inflammatory phase. A careful history may reveal use of a perfume or fragrance-containing product on the skin prior to a period of sun exposure, such as sunbathing or a picnic. If untreated, the natural history of the disease also is biphasic; the inflammatory lesions resolve in days to weeks, but the pigmentation may last months or even years. PhysicalErythema, edema, vesiculation, hyperpigmentation, and desquamation are typical phototoxic skin effects. In classic berloque dermatitis, brown hyperpigmentation with or without preceding erythema is seen in a droplike or pendantlike configuration. It usually is distributed over the sides of the neck in adult females, although it may be seen in any part of the body where perfume was applied followed by sun-exposure. Some less typical presentations of berloque dermatitis are, for example, symmetrical facial pigmentation on a man, caused by aftershave lotion containing bergapten, and an infant who developed pigmentation on her body and arms where her mother applied eau de toilette prior to taking her to the beach. CausesBergapten, or 5-methoxypsoralen, is the photoactive component of bergamot oil from the bergamot lime (C bergamia), which is a popular ingredient in perfumes and fragrances. Apart from their obvious existence in cosmetics and toiletries (such as toilet water, aftershave lotions, colognes, sunscreen lotions, moisturizers), perfumes also are found in soap, household cleaners, detergents, air fresheners, and a myriad of other everyday items. Besides the bergamot lime, bergapten is a naturally occurring component of various other fruits and plants (see Media File 3). Examples of these are figs (Ficus carica), celery (Apium graveolens), lemon oil, Tromso palm (H laciniatum), Queen Anne's lace (Ammi majus), and giant Russian hogweed (H mantegazzianum). All these are capable of inducing bergapten phototoxicity, although they are not perfume-related and, therefore, classified as phytophotodermatitis rather than berloque dermatitis. DIFFERENTIALSSection 4 of 9
Acanthosis Nigricans Contact Dermatitis, Allergic Contact Dermatitis, Irritant Melasma Phytophotodermatitis Riehl Melanosis WORKUPSection 5 of 9
Lab Studies
Other Tests
Histologic FindingsThe histopathological findings in berloque dermatitis are identical to other phototoxic reactions, an irritant cutaneous response. The epidermal changes consist of keratinocyte necrosis, intercellular and intracellular edema, and intraepidermal blisters. In severe cases, these blisters may rupture, resulting in subepidermal bullae. Neutrophils enter the epidermis at an early stage. In contrast to the extensive epidermal damage, only a mild perivascular infiltrate is present. Changes associated with berloque pigmentation are an increased number and size of melanosomes, melanocyte hypertrophy with increased arborization of dendrites, increased transfer of melanosomes to keratinocytes, and increased tyrosinase activity within the proliferating melanocytes. TREATMENTSection 6 of 9
Medical CareThe primary aim of the therapeutic regime is discontinuation of the offending substance. If berloque dermatitis is the putative diagnosis, all bergamot oil-containing perfumes should be avoided. Any perfumes that are worn should be worn on covered-up areas, not on areas of sun exposure. If the patient presents in the acute phase and is in considerable discomfort, wet compresses may be helpful in relieving the discomfort. Simple analgesia may be given if the patient is in pain. For secondary hyperpigmentation, the natural course of the dermatitis is spontaneous resolution after several months, but some lesions may persist much longer. The most important step is to minimize exposure to the sun. This may be done by avoiding strong sunlight whenever possible, avoiding the use of sunbeds and using a strong sunscreen (SPF 30 or higher) with activity in both the UVA and UVB spectra. Camouflage also may be used on exposed hyperpigmented areas, for cosmetic reasons. Dermablend and Covermark are preparations combining a water-resistant opaque base with a broad-spectrum sunscreen. If the pigmentation is persistent, hydroquinone constitutes the mainstay of medical therapy. It usually is given twice a day, at a concentration of about 2%, for several months. At higher concentrations, the patient would be at risk of irritation. Hydroquinone sometimes is administered in conjunction with topical tretinoin (Retin-A). Kligman and Willis16 devised a concoction known as Kligman's formula, consisting of hydroquinone, tretinoin, dexamethasone, ethanol, and propylene glycol, which they found effective in treating hyperpigmentation. A novel therapy for pigmentary disorders is ellagic acid, now commercialized in Japan. Ellagic acid is a naturally existing polyphenol that inhibits tyrosinase activity by chelation of the copper ion(s) at the active center of the enzyme. The efficacy in a placebo-controlled trial for preventing UV-induced pigmentation has been shown to be 86%, and no side effects have been reported. MEDICATIONSection 7 of 9
Medical therapy is largely unnecessary for the treatment of berloque dermatitis, except in cases with persistent hyperpigmentation. In these cases, skin-bleaching agents (eg, hydroquinone) are the mainstays of therapy.
Drug Category: Depigmenting agentsSkin bleaching agents are indicated for the gradual depigmentation of hyperpigmented skin conditions.
MULTIMEDIASection 8 of 9
REFERENCESSection 9 of 9
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