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Peru Balsam

Scientific Name(s): Myroxylon balsamum (L.) Harms var. pereirae (Royle) Harms.
Common Name(s): Balsam of Peru, Balsamo blanco, Baumier du Perou, Black balsam, Indian balsam, Peru balsam, Perubalsambaum, Peruvian balsam

Clinical Overview

Use

Peru balsam has been used in the treatment of dry socket in dentistry, topically as a treatment for wounds and ulcers, and in suppositories for hemorrhoids. However, there are only older, small case studies to support this use. The material is not used internally.

Dosing

Peru balsam has been used topically in 5% to 20% formulations for wounds and burns. Case reports and small clinical studies report the efficacy of balsam combined with other ingredients in the management of certain wounds; however, there are no recent, well-controlled clinical studies to support appropriate dosing.

Contraindications

Contraindications have not been identified.

Pregnancy/Lactation

Information regarding safety and efficacy in pregnancy and lactation is lacking. Systemic toxicity following application of Peru balsam to the nipples of breast-feeding mothers has been reported.

Interactions

None well documented.

Adverse Reactions

Peru balsam is an allergen. The use of its constituents is widespread and found in cosmetics as well as foods, including ketchup. Cross-reactivity with naturally occurring sources of similar chemicals has been reported with orange peel, clove, and tomatoes.

Toxicology

Information is lacking.

Botany

The species Myroxylon balsamum is a tall tree (15 to 23 m high) native to the high plains and mountains of Central and South America. The plant bears evergreen pinnate leaves and racemes of white flowers. The hardwood tree contains oil that is naturally resistant to insects and has a characteristic scent. The plant is the only species within the genus Myroxylon; however, there are 2 varieties, var. pereirae and var. balsamum, known as balsam of Peru and balsam of Tolu, respectively. (See Tolu Balsam).Duke 2002, USDA 2012 Synonyms are Myroxylon pereirae (Royle) Klotzsch, Myrospermum pereirae Royle (basionym), and Toluifera pereirae (Royle) Baill.

History

Crude Peru balsam is a dark brown, thick liquid with an aromatic smell similar to that of cinnamon and vanilla and a bitter taste. It is obtained from the tree after the bark has been removed. The trunk is wrapped with rags that are later boiled to extract the resin.Leung 2003

The balsam was imported almost exclusively from El Salvador to Europe through Peruvian ports, which is how the material derived its name.Amado 2006, Evans 1989 Central and South American natives used the material to stop bleeding and promote wound healing. They also used the material as a diuretic and to expel worms. Formerly, it was used widely as a treatment for scabies; it has also been used in suppositories for hemorrhoids and in dentistry in the treatment of dry socket (postextraction alveolitis) and as a component of dental impression material. Today, the material is in a number of pharmaceutical preparations and plays an important role in perfumery. It is not used as an internal medication.Leung 2003, Osol 1955

Chemistry

The balsam contains 50% to 65% of a volatile oil called cinnamein, along with about 25% resin. The volatile oil primarily contains benzyl cinnamate and other benzoic and cinnamic acid esters, with small amounts of benzyl alcohol and related compounds. In addition, traces of styrene, vanillin, and coumarin have been identified in the material. Oil distilled from the wood is about 70% nerolidol. Considerable chemical variations exist in the balsam, depending on the source of the material.Duke 2012, Evans 1989, Leung 2003

Uses and Pharmacology

Wound healing

Animal data

Combined with zinc oxide and bismuth oxide, Peru balsam was used in the management of a wound following the removal of squamous cell carcinoma in a white rhinoceros.Goodman 2007

Clinical data

Studies have evaluated the use of Peru balsam as a treatment of partial-thickness wounds. Some benefit has been shown for the use of a castor oil–balsam of Peru–trypsin ointment as treatment for skin graft donor sites, moist desquamation after radiation, wound care after tissue debridement, and skin tissue damage from heparin-induced thrombocytopenia, but only in small studies or case reports.Beitz 2005, Carson 2003, Glenn 2006, Gray 2004, McDougall 2005, Thomas 2008

Other

Antimicrobial properties have been described for the balsam, and applications such as use against mosquito larvae and pathogenic bacteria have been investigated.de Barros Machado 2005, Seo 2012

Dosing

Peru balsam has been used topically in 5% to 20% formulations for wounds and burns; however, there are no recent, well-controlled clinical studies to support appropriate dosing. Use of the balsam is documented in the Complete German Commission E Monographs for poorly healing wounds, burns, frostbite, bruises, and hemorrhoids.Blumenthal 2000

Pregnancy / Lactation

Information regarding safety and efficacy in pregnancy and lactation is lacking. Systemic toxicity following application of Peru balsam to the nipples of breast-feeding mothers has been reported.Duke 2002

Interactions

None well documented.

Adverse Reactions

Peru balsam is a contact allergen, and contact dermatitis occurs frequently with the product.Balato 2011, Krob 2004, Nijhawan 2009, Thyssen 2009 In a systematic review of 34 studies covering a 15-year period, it was found to be among the top 10 most common allergens in adolescents and a less common antigen in children. Equivocal data prevented an association being made with atopic vs non-atopic individuals.Rodrigues 2016 It may cause dermatitis in individuals who have a sensitivity to benzoin resinoids. The main contact sensitizers in Peru balsam have been identified and include cinnamates, benzoates, and terpenoids. Additional patch testing is recommended in Peru balsam–sensitive individuals to trace the origins of sensitization.Hausen 2001, Srivastava 2009 As a basic screening tool to improve detection and management of allergic contact eyelid dermatitis cases, balsam of Peru 25% in petrolatum has been recommended as a standard patch-test component based on data supporting its high frequency as a relevant antigen.Herro 2012

The importance of recognizing food items that contain balsam of Peru-associated constituents was highlighted in a case series of 7 children with systemic manifestations of recalcitrant dermatitis. Thorough questioning revealed that all 7 patients had significant ketchup intake (from daily to 3 times/week). Instituting a low balsam of Peru diet that included avoidance of ketchup achieved 80% improvement in 5 of the 7 children, 70% in the 6th child, and 60% improvement in the 7th. Cross-reactivity with food sources that naturally contain chemicals similar to the volatile oils and resins in balsam of Peru include orange peel, clove, and tomatoes. The 5 foods listed on the avoidance list for the low balsam of Peru diet were tomatoes and tomato-containing products, peels of citrus fruits, chocolate, cola and spiced sodas, and cinnamon, cloves, and vanilla.Herro 2013 Similarly, initiation of a low balsam of Peru diet improved pruritic allergic dermatitis symptoms in a 48-year-old man within 1 month of dietary changes, which was sustained for several months.Nanda 2016 Cases of cheilitis and perioral dermatitis have been reported in 2 individuals who used Lucas Papaw ointment, which included small amounts of Myroxylon pereirae that was not listed as an ingredient on the labeling but was later confirmed by the manufacturer.Tan 2011

Toxicology

Information is lacking.

References

Amado A, Taylor JS. Balsam of Peru or balsam of El Salvador? Contact Dermatitis. 2006;55(2):119.16930242
Balato A, Balato N, Di Costanzo L, Ayala F. Contact sensitization in the elderly. Clin Dermatol. 2011;29(1):24-30.21146728
Beitz JM. Heparin-induced thrombocytopenia syndrome bullous lesions treated with trypsin-balsam of peru-castor oil ointment: a case study. Ostomy Wound Manage. 2005;51(6):52-54, 56-58.16014993
Blumenthal M, Goldberg A, Brinckmann J, eds. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications; 2000.
Carson SN, Wiggins C, Overall K, Herbert J. Using a castor oil-balsam of Peru-trypsin ointment to assist in healing skin graft donor sites. Ostomy Wound Manage. 2003;49(6):60-64.12874484
de Barros Machado T, Leal IC, Kuster RM, et al. Brazilian phytopharmaceuticals—evaluation against hospital bacteria. Phytother Res. 2005;19(6):519-525.16114081
Dr. Duke's Phytochemical and Ethnobotanical Databases [Online Database]. http://www.ars-grin.gov/duke/. Accessed July 22, 2012.
Duke JA. Handbook of Medicinal Herbs. 2nd ed. Boca Raton, FL: CRC Press; 2002:133-239.
Evans WC. Trease and Evans' Pharmacognosy. 13th ed. London: Bailliere Tindall; 1989.
Glenn J. Managing a traumatic wound in a geriatric patient. Ostomy Wound Manage. 2006;52(4):94-98.16636366
Goodman G, Rhind S, Meredith A. Successful treatment of a squamous cell carcinoma in a white rhinoceros, Ceratotherium simum. Vet Dermatol. 2007;18(6):460-463.17991166
Gray M, Jones DP. The effect of different formulations of equivalent active ingredients on the performance of two topical wound treatment products. Ostomy Wound Manage. 2004;50(3):34-38, 40, 42-44.15206088
Hausen BM. Contact allergy to balsam of Peru. II. Patch test results in 102 patients with selected balsam of Peru constituents. Am J Contact Dermat. 2001;12(2):93-102.11381345
Herro EM, Elsaie ML, Nijhawan RI, Jacob SE. Recommendations for a screening series for allergic contact eyelid dermatitis. Dermatitis. 2012;23(1):17-21.22653064
Herro EM, Jacob SE. Systemic contact dermatitis--kids and ketchup. Pediatr Dermatol. 2013;30(3):e32-e33.22299798
Krob HA, Fleischer AB Jr, D'Agostino R Jr, Haverstock CL, Feldman S. Prevalence and relevance of contact dermatitis allergens: a meta-analysis of 15 years of published T.R.U.E. test data. J Am Acad Dermatol. 2004;51(3):349-353.15337975
Leung AY, Foster S. Encyclopedia of Common Natural Ingredients Used in Food, Drugs, and Cosmetics. 2nd ed. Hoboken, NJ: Wiley-Interscience; 2003.
McDougall CJ, Franklin LE, Gresle SO. Management of radiation dermatitis in a patient after mastectomy. J Wound Ostomy Continence Nurs. 2005;32(5):337-339.16234729
Nanda A, Wasan A. Allergic contact dermatitis to balsam of Peru. Ann Allergy Asthma Immunol. 2016;117(2):208-209.27499544
Nijhawan RI, Molenda M, Zirwas MJ, Jacob SE. Systemic contact dermatitis. Dermatol Clin. 2009;27(3):355-364, vii.19580929
Osol A, Farrar GE Jr, eds. The Dispensatory of the United States of America. 25th ed. Philadelphia, PA: J.B. Lippincott; 1955:1023.
Rodrigues DF, Goulart EM. Patch-test results in children and adolescents: systematic review of a 15-year period. An Bras Dermatol. 2016;91(1):64-72.26982781
Seo SM, Park HM, Park IK. Larvicidal activity of ajowan (Trachyspermum ammi) and Peru balsam (Myroxylon pereira) oils and blends of their constituents against mosquito, Aedes aegypti, acute toxicity on water flea, Daphnia magna, and aqueous residue. J Agric Food Chem. 2012;60(23):5909-5914.22620984
Srivastava D, Cohen DE. Identification of the constituents of balsam of peru in tomatoes. Dermatitis. 2009;20(2):99-105.19426616
Tan S, Tam MM, Nixon RL. Allergic contact dermatitis to Myroxylon pereirae (Balsam of Peru) in papaw ointment causing cheilitis. Australas J Dermatol. 2011;52(3):222-223.21834822
Thomas R. Acoustic pressure wound therapy in the treatment of stage II pressure ulcers. Ostomy Wound Manage. 2008;54(11):56-58.19037138
Thyssen JP, Menné T, Linneberg A, Johansen JD. Contact sensitization to fragrances in the general population: a Koch's approach may reveal the burden of disease. Br J Dermatol. 2009;160(4):729-735.19210499
USDA, ARS, National Genetic Resources Program. Germplasm Resources Information Network - (GRIN) [Online Database]. National Germplasm Resources Laboratory, Beltsville, Maryland. http://www.ars-grin.gov/cgi-bin/npgs/html/taxon.pl?70454. Accessed July 19, 2012.

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This information relates to an herbal, vitamin, mineral or other dietary supplement. This product has not been reviewed by the FDA to determine whether it is safe or effective and is not subject to the quality standards and safety information collection standards that are applicable to most prescription drugs. This information should not be used to decide whether or not to take this product. This information does not endorse this product as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this product. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this product. This information is not specific medical advice and does not replace information you receive from your health care provider. You should talk with your health care provider for complete information about the risks and benefits of using this product.

This product may adversely interact with certain health and medical conditions, other prescription and over-the-counter drugs, foods, or other dietary supplements. This product may be unsafe when used before surgery or other medical procedures. It is important to fully inform your doctor about the herbal, vitamins, mineral or any other supplements you are taking before any kind of surgery or medical procedure. With the exception of certain products that are generally recognized as safe in normal quantities, including use of folic acid and prenatal vitamins during pregnancy, this product has not been sufficiently studied to determine whether it is safe to use during pregnancy or nursing or by persons younger than 2 years of age.

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