Commentary: Think anaphylaxis

Besides the experience of the earthquake and tsunami disaster, the year 2011 became a memorable year for allergologists and cosmetologists in Japan, because of the notification of a widespread contact allergy to wheat caused by a popular facial soap, ‘Cha-no-shizuku’ (a drop of green tea). In some cases, such wheat allergies develop into life-threatening anaphylaxis after eating wheat products. This public health issue was first announced to the public by the Consumer Affairs Agency of Japan with 67 cases in May 2011 and is still attracting huge attention to date. This announcement resulted in the flooding of reports to the Japanese Society of Allergology (JSA), with the latest report from the JSA in 25 November citing 569 cases, including about one third of anaphylactic cases (1). In December 2011, despite the sincere apology and announcement of product callback by the manufacturer, ‘Yuuka’, patient groups started legal actions against the company to acquire compensation for their injuries and disabling their safe oral intake of wheat products, and trials have begun in Japanese district courts.

Generally, wheat allergy takes the form of wheat-dependent exercise-induced anaphylaxis (WDEIA), in which patients experience a systemic type I allergy after combining wheat intake and moderately intense physical activities. The anaphylactic symptoms of this ‘classic WDEIA’ are urticaria of the entire body, difficulty in breathing, cold sweat, and finally loss of consciousness, during or just after exercise within several hours of wheat intake. In the ‘soap-triggered WDEIA’ cases in Japan, the patients taken to the hospital presented with symptoms to similar to classic WDEIA; however, the difference was that the episodes were always preceded by several months of continuous use of the product and contact urticaria with sneezing after washing with the soap. In the soap-triggered WDEIA cases, skin prick testing with the soap itself and wheat extracts was reported to be useful for diagnosis (2). Although reports of such cases of contact sensitisation to wheat can be found in some European literature (3-5), I have not found any report on a widespread WDEIA issue triggered by a skincare product. This sensitisation is difficult to diagnose because both patients and doctors could not clinically link the soap and the WDEIA. As a result, no patient had been correctly confirmed to have the soap-triggered WDEIA attack until early 2010, 4 years after the launch of the product. However, after 3 of such cases were first reported in Japanese literature in May 2010 (1), specialists became gradually aware of this anaphylaxis and reports of similar cases started to accumulate in the country (6,7).

In November 2011, the JSA announced that the causative agent was ‘Glupearl-19S’, a degraded gluten made from the direct resolution of wheat by hydrochloric acid. Cha-no-shizuku soap contains 0.3% of this agent, and it is clinically obvious that several months’ use of the product could cause the percutaneous sensitisation (8). Additional evidence is provided by a retrospective study of consumers of other minor products that contain the same agent, which revealed similar anaphylaxis cases. Investigation into the exact mechanism of this sensitisation is still in progress.

Adding degraded wheat to skincare products to render a foamy or adhesive characteristic, is a common practice worldwide. I am describing this domestic problem to English-speaking readers because I fear that similar problems may occur in other places around the world now or in the near future.

References
1 Newspaper ‘The Asahi Shimbun’ 15 December 2011. (In Japanese)
2 Chinuki Y, Sakieda K, Kaneko S, Nakamura C, Murata S, Sumikawa Y, et al. Three cases of wheat-dependent exercise-induced anaphylaxis possibly sensitized by hydrolyzed wheat proteins in soap. Jpn J Dermatol 2010; 120: 2421–5. (In Japanese)
3 Varjonen E, Petman L, Mäkinen-Kiljunen S. Immediate contact allergy from hydrolyzed wheat in a cosmetic cream. Allergy 2000; 55: 294–6.
4 Laurière M, Pecquet C, Bouchez-Mahiout I, Bayrou O, Raison-Peyron N, Vigan M. Hydrolysed wheat proteins present in cosmetics can induce immediate hypersensitivities. Contact Dermatitis 2006; 54: 283–9.
5 Hann S, Hughes M, Stone N. Allergic contact dermatitis to hydrolyzed wheat protein in a cosmetic cream. Contact Dermatitis 2007; 56: 119–20.
6 Chinuki Y, Kaneko S, Sakieda K, Murata S, Yoshida Y, Morita E. A case of wheat-dependent exercise-induced anaphylaxis sensitized with hydrolysed wheat protein in a soap. Contact Dermatitis 2011; 65: 55–7.
7 Fukutomi Y, Itagaki Y, Taniguchi M, Saito A, Yasueda H, Nakazawa T, et al. Rhinoconjunctival sensitization to hydrolyzed wheat protein in facial soap can induce wheat-dependent exercise-induced anaphylaxis. J Allergy Clin Immunol 2011; 127: 531–3.
8 The Rheumatism & Allergy Information Centre webpage, http://www.allergy.go.jp/allergy/flour/001.html (In Japanese)