By Betty Bridges, RN
Fragranced Products Information Network
http://www.fpinva.org
fpinva@fpinva.org

Some 25 years ago health care workers were routinely taught to refrain from using scented products because those that are ill are more sensitive to odors and fragrances can irritate respiratory disorders. Unfortunately, many nurses seem to be unaware of negative effects scented products may have on their patients, their coworkers, and indoor air quality.

The use of scented products has soared since the 1970s. Perfumes and colognes have gone from special occasion use to daily wear. Toiletries, cleaners, and laundry products are often highly scented as well. Scented products have been formulated with increasingly intense and long lasting scents. As usage has increased, problems have emerged. There is a general lack of awareness, even among health care staff.

To increase awareness among health care staff of problems associated with fragrance and enable accommodation of fragrance sensitive patients.

The most commonly documented adverse effects of fragrance are skin irritation and allergy. An estimated 1-2% of the general population has skin allergy to fragrance. A recent German study suggests that up to 11% of the general population may have skin allergies.(1) There is a direct correlation between use and development of skin allergy. Once allergies occurs, continued exposure can increase sensitization to the point even minute exposures can trigger symptoms. Some people are so sensitive that the fragrance in the air can trigger dermatitis. Nurses are among the occupations that have a higher frequency of skin allergy to fragrance.

Materials used in fragrance are skin irritants. Irritants can cause dermatitis and increase the susceptibility of the skin to other irritants, allergens, and harmful materials. Fragrance can also cause skin sensitivity to the sun and hyperpigmentation.

The skin provides an entry point into the body for chemicals. Once materials enter the body, they can impact any system or organ. Synthetic musk compounds are found in blood, fat tissue, breast milk of humans, and cross the placental barrier in animal studies. Commonly used nitromusks are probably carcinogens or increase the carcinogenic effects of other materials.(2) The presence of these materials in breast milk raises concerns about possible connection with breast cancer and impact on nursing infants.

Olfactory pathways provide a direct connection to the brain. Fragrance materials have been found to impact pulse rate, blood pressure, motility, and have other physiological effects.(3) Odorants can cause both physical and emotional responses.

Solvents in fragrance such as toluene have known neurological effects. A synthetic musk known as AETT was found to target the nerves and cause permanent damage to the nerves.(4) Similar materials continue to be in common use without evaluation of neurological effects. Fragrance is a known trigger for migraine headaches. Experiments with fragrance chemicals found that some affected autonomic nervous system parameters such as pulse, heart rate, blood pressure and mood in humans.(5) Another study suggests that fragrance may act on the same receptors in the brain as alcohol and tobacco.(6)

There is increasing concern and evidence that fragrances plays a role in triggering, exacerbating, and even causing asthma, allergies, sinus problems, and other respiratory related disorders. Research raises concerns.

In a Swedish study, 15% of the general population found fragrance to be a lower respiratory irritant.(7) Up to 72% of asthmatics cite fragrance as a trigger their asthma,(8) a Tulane University study found that popular perfumes are triggers for asthma.(8) and scented strips in magazines are triggers as well.(8) A health care worker sprayed in the face with perfume had an anaphalatic response and developed asthma.(10)

The Institute of Medicine reviewed medical literature on the impact of indoor pollutants on asthma. This review placed second hand smoke, fragrance, and formaldehyde in the same category in triggering asthma in adults and school age children.(11) Most agencies and organizations concerned with respiratory health list fragrance as a trigger for asthma.(12)

Fragrances can contribute to respiratory problems in several ways. Irritants increase susceptibility to other irritants, allergens, pathogens, and toxins. Those with respiratory disorders and in compromised health are more susceptible to the effects.

There is thought to be a neurological component to asthma. Not only are fragrance compounds skin and respiratory irritants, they can also stimulate the trigeminal nerve. About 70% of fragrance compounds stimulate the trigeminal nerve to some degree.

Most are volatile or semi-volatile compounds, which get into the air quickly and add to indoor air pollution. Other materials contribute to the formation of tiny particles that are essentially "indoor smog" (13) Tiny particles in the air are associated with triggering and exacerbating respiratory conditions and are thought to damage the lungs.

Outdoor air is affected as well. A study in Norway found synthetic musk compounds in outdoor air, even in remote areas.(14) Though most scented products are used indoors, through air exchange and venting, they end up outside as well. Air is not the only environmental concerns.

Synthetic musk compounds are found in waterways. These materials accumulate in aquatic wildlife in a similar manner as pesticides and other persistent organic pollutants.   Products such as shampoos, laundry products, and cleaners end up going down the drain. Wastewater treatments do not remove the fragrance chemicals.(15) If materials that do not persist in the environment may act as they do because the supply is continually replenished.

One has to ask, if fragrances pose such concerns, why is there so little awareness? There are many complicating factors such as secrecy of the fragrance industry, lack of regulation, general perceptions regarding fragrance, and the process of detecting odors.

The ingredients in fragrance are "trade secrets" and do not have to be revealed on the label. There is no way of knowing which products contain problematic materials and which do not. Most of testing for safety of materials used in fragrance focuses on skin effects. Testing for respiratory, neurological, and systemic effects are not a part of routine testing.

There is no legal requirement for testing of fragrance materials before marketing (16) Products that are considered cosmetics (toiletries, perfumes, makeup, etc.) are required to have a warning label if the safety of all the ingredients and the final product has not been substantiated. Though most fragrance materials have not had the safety substantiated for respiratory, neurological, and systemic effects, the products do not carry the required warning label.

There is little readily available information or education regarding fragrance. People generally perceive fragrance as a form of self-expression, certainly not as something that is potentially harmful. The products used on one's person are usually assumed to be an individual choice. Very often restrictions on use are considered an affront to personal rights.

Clever marketing has molded perceptions. Our homes, bodies, and spaces must be scented in order to be perceived as clean. Fragrance makes us attractive, desirable and even a good mother. Fragrance has the power to relax, stimulate, and otherwise alter our moods.

Because of limitations of the sense of smell, those that use or around scented products on a routine basis, are much less aware of their presence. The sense of smell detects changes in the environment. Once around an odor for a period of time, the odor is no longer noticeable or less noticeable. Within an hour or two of application, the user is no longer aware of the odor from the scented products they use. Odor from laundry products may not be noticed at all as there is continuous exposure. Very often users of scented products think the fragrance has worn off and will reapply.

The very nature of health care requires close personal contact with patients. Those that are ill are often more sensitive to odors. Even a whiff of fragrance can trigger migraine headaches in susceptible populations. Further irritants such as fragrance or second hand smoke on clothes or hair can be a respiratory irritant. Those with respiratory disorders are even more sensitive to irritants when ill. The threshold for triggering an attack is much lower. Even if an acute attack is not triggered, irritants can increase the inflammatory processes involved in respiratory diseases and infections. This can lead to episodes that do not manifest themselves until hours after the exposure. Exposure to irritants also increases susceptibility to other irritants, allergens, and pathogens.

Fragrance is designed to get into the air. Once in the air, it can not be contained. This makes it important that all staff that is in areas patients may access refrain from using scented products. This includes unit secretaries, ancillary staff such as lab, x-ray, and respiratory therapy. Social workers, dietitians, and others that may have contact with patients need to be aware of problems associated with fragrance as well. The nurse must play a role as a patient advocate and protect the patient that has fragrance sensitivities from exposure.

Odors from body fluids and excrement are often present in health care facilities. This leads to the use of products such as air fresheners, cleaners that contain scent, and sprays to cover odor. These products simply mask odors, add to the pollutants in the air, and can contain toxic materials.(17) Ventilation, good housekeeping, and other measures that do not add pollutants to the air should be used. Unfortunately, many commercial cleaning products used in hospitals have added fragrance. These products pose significant risk for those that are fragrance sensitive.

There are degrees of sensitivity to fragrance. For some only minor symptoms are triggered, while others are moderately affected. For others the problems are much more serious. Some asthmatics have life-threatening hypersensitivity attacks triggered by even small amounts of fragrance. Severe migraine headaches and other neurological problems can be triggered in others.

For these patients special precautions must be taken to protect their health. Patients that are that sensitive usually try to notify the facility before hand. However, there are many instances where previous notice cannot be given. Facilities need to be prepared to accommodate those with severe fragrance sensitivity.

Housekeeping should receive specific instructions when preparing rooms for fragrance sensitive patients. Baking soda, vinegar, and plain water should be used to clean the room. Rooms that have carpet should be vacuumed well ahead of the patient's admission to the room to allow any fragrance that was stirred up from the carpet to settle out of the air. If possible increase air exchange to increase ventilation. Scented soaps and toiletries should be removed from the room. Allow patients to use their own sheets and laundry if needed.

Patients play a primary role in managing any medical condition. This is especially true of diseases such as asthma that are triggered or exacerbated by environmental exposures. Avoiding triggers at home, school, work, and social activities is crucial. When assessing a patient for education needs, include questions about scented products. Find out what types of scented products are used in the household and by the patient. Remember to include questions about laundry products, cleaners, and toiletries. Even items such as trash bags may come in scented versions.

Since there is such constant exposure to scented products, the patient may not be aware of the impact on his or her health. Suggest the patient try to avoid scented products for several weeks and see if health improves. This is an especially important step for parents with asthmatic children. Children, especially infants and young children are not able to communicate what triggers their breathing problems.

Not every patient is extremely sensitive to fragrance. However, the irritant property may increase the underlying inflammatory process. Even patients that are not obviously sensitive to fragrance should avoid high concentrations. When scented products are applied, it should be in a well ventilated area. During attacks and exacerbation, all irritants including fragrance should be avoided.

Home environments are easier to control than school, work, and social environments. There may be a need for information that can be shared with school or work. Often a letter from the doctor is required when accommodation is needed at school or work.

Women that are pregnant, planning on getting pregnant, or breast feeding should be aware that it is prudent to avoid as many chemical exposures as possible. Many women are not aware that scented products contain materials that accumulate in body tissues, cross the placental barrier, and are present in breast milk. Avoiding products that contain scent is prudent.

It is essential that direct care staff be aware of implications of scented products in the workplace. The very nature of health care often includes both close contact and patients that are negatively impacted by fragrance. For those that have serious sensitivities, fragrance can exacerbate illness and pose a barrier to accessing health care. Avoiding use of fragrance in the clinical setting helps improve air quality and aids in preventing the development of occupational allergies to fragrance. Nurses are often responsible for patient teaching. It is important for those with asthma and other respiratory disorders to be aware that exposure to scented products may trigger or exacerbate their illness. Pregnant and nursing mothers should know there is exposure to the babies to fragrance materials before birth and when nursing. It is prudent to avoid exposures to chemicals during pregnancy and breast-feeding, this includes exposure to fragrance.

Nurses can play an important role in educating on emerging health issues and providing a safer environment for patients, their coworkers and themselves.

1. Identify 5 health conditions that are triggered or exacerbated by fragrance
2. Identify 10 items that are commonly used on one's person that contain fragrance.
3. Identify 5 items used in the work environment that may contain fragrance.
4. Take measures to protect patient that is severely fragrance sensitive in Case Study 1.
5. Educate patient in Case study 2 that may be negatively impacted by fragrance.