1) Dermal exposure can cause erythema, but not vesiculation. Eye exposure to the pepper juice can produce moderate chemical conjunctivitis and pain. Oral exposure can cause burning and stinging of the oral mucosa.

1) The more severe outcomes, requiring medical evaluation, included ocular symptoms (ie, persistent pain, blurred vision, foreign body sensation, discharge or exudate, periorbital swelling), dermal symptoms (ie, rash, blisters), and respiratory symptoms (ie, shortness of breath, chest tightness, wheezing) (Kearney et al, 2014).

1) "Pepperball Tactical Powder" pellets have been used to control riots. Each pellet weighs just over 3 grams and has a thin rigid plastic casing (diameter 17.2 mm). It has 2.45 grams of a white powder containing capsaicin, present as a 0.5% (w/w) mixture with barium sulfate and non-crystalline amorphous precipitated silica. When pellets are fired, the plastic casing will rupture on impact and the contents will be discharged (Hay et al, 2006).

a) Submucous fibrosis is a condition in which changes in the connective tissue of the palate occurs, was seen in India where there is a high intake of chili peppers. Recurrent oral vesicle formation was seen in 13% of one series of 104 cases (Smith et al, 1970).

a) Nausea and vomiting may occur after ingestion of the plant containing capsaicin (Morton, 1971; Tominack & Spyker, 1987; Snyman et al, 2001) or following contact with pepper spray (Forrester & Stanley, 2003).
b) Nausea has been reported in individuals exposed to "Pepperball Tactical Powder" pellets containing capsaicin. These pellets have been used to control riots (Hay et al, 2006).

a) Diarrhea was seen in children who had jalapeno peppers and Tabasco(R) sauce placed in their mouth as punishment. An anal burning sensation also occurred (Tominack & Spyker, 1987).

a) Epithelial cell damage and destruction may occur in the gastrointestinal tract with chronic administration of capsaicin (Desai et al, 1976).
b) The effects on mucosal surfaces may range from mild erythema to edema and minute hemorrhagic spots (Viranuvatti et al, 1972; Desai et al, 1977; Kumar et al, 1984).
c) Studies done in rats (Lippe et al, 1989; Holzer, 1989) and in humans (Graham et al, 1988), have failed to demonstrate gastric mucosal injury from capsicum.
d) The administration of meals containing red pepper (0.1 to 1.5 g) or black pepper (1.5 g) to healthy human volunteers caused gastric cell exfoliation. Mucosal micro-bleeding was seen after spice administration and one subject had grossly visible gastric bleeding (Myers et al, 1987).

a) Capsaicin is a lipid soluble phenol that may produce a pungent taste to water at a concentration of 1 to 11 parts per million of water (Tyler et al, 1981).

a) CASE REPORT: A 47-year-old man presented to the emergency department with severe abdominal and chest pain associated with severe retching and vomiting after eating ghost peppers a pepper grown in India and considered one of the hottest chili peppers with a measured "heat" of 1,000,000 Scoville Heat Units that is more than twice that of a habanero pepper. The patient was unresponsive to supportive therapy, including administration of an antacid, lidocaine and NG tube placement and lavage, and a chest x-ray was performed, revealing left-sided pleural effusion and patchy infiltrates. Pneumomediastinum with air around the distal esophagus, indicating a possible esophageal perforation (a 2.5 cm tear was present in the distal esophagus) and left-sided pneumothorax, was observed with an abdominal and pelvis CT scan and was confirmed with surgical intervention. Following surgery, the patient's hospital course was complicated with transient hypotension and a right sided pleural effusion requiring chest tube placement. The patient was extubated on day 14. With continued supportive care, the patient slowly improved with the ability to tolerate liquids on hospital day 17 (Arens et al, 2015).

a) One study done on Thai people who eat capsicum-containing peppers daily showed higher antithrombin III, lower plasma fibrinogen, increase fibrinolytic activity, and hypocoagulability (Visudhiphan et al, 1982).

a) ANIMALS: Capsicum inhibited platelet aggregation more potently than aspirin or indomethacin, but did not alter blood coagulation as measured by PT or PTT (Wang et al, 1985).

a) Erythema and burning without vesiculation often occurs when applied topically to human skin (Smith et al, 1970; Burnett, 1989; Watson et al, 1996; Herman et al, 1998a), but blistering and rash may occur, especially after chronic or prolonged exposures (Morton, 1971).
b) Exposure to pepper-mace spray containing 5% capsaicin has been reported to cause immediate and severe discomfort to the skin (Herman et al, 1998). Treatment with a topical solution of magnesium hydroxide/aluminum hydroxide/simethicone suspension improved symptoms immediately and then resolved completely within 2 minutes of topical application.
c) "Pepperball Tactical Powder" pellets containing capsaicin have been used to control riots. When pellets are fired, the plastic casing ruptures on impact and the contents are discharged. Exposed individuals have experienced severe pain, erythema, stinging, and swelling. The injury sites may become infected, may cause scarring, and may heal with subsequent hyperpigmentation (Hay et al, 2006).
d) According to a retrospective review of cases reported to the California Poison Control System between 2002 and 2011, 249 of 3671 (6.8%) cases reported pepper spray exposure in individuals 6 years of age or older who had severe outcomes warranting medical evaluation. Of the 249 patients, 44 patients (17.7%) reported rash and blisters (Kearney et al, 2014).

a) A condition in which an intense burning sensation and pain in the hands, possibly radiating up the arms, may occur after the hands are exposed to capsaicin-containing peppers during cooking or meal preparation. . Actual burns do not usually appear (Weinberg, 1981).
b) "Pepperball Tactical Powder" pellets containing capsaicin have been used to control riots. When pellets are fired, the plastic casing will rupture on impact and the contents will be discharged. Exposed individuals have experienced severe pain, erythema, stinging, and swelling (Hay et al, 2006).

a) Workers handling wet chilies developed dermatitis of the hands; the irritant even appears to penetrate rubber gloves. The dried fruit of plants containing capsaicin may have a vesicant effect, but in most cases, simply produces a burning sensation and mild erythema.

a) RATS: The aqueous extract of the fruits of Capsicum annum L of tropical regions caused a dose-dependent decrease in fasting blood glucose levels in rats either by oral or intraperitoneal route of administration.

a) Repeated dosing may not produce actual desensitization but rather a mental attitude change that permits tolerance (Rozin et al, 1982).
b) Desensitization to the burning sensations and the rhinorrhea induced by topical capsaicin (75 mcg) developed and these effects were completely abolished after 4 to 5 applications of the drug (Geppetti et al, 1988).
c) Desensitization of chemosensitive unmyelinated sensory nerve fibers with eventual loss of local tissue reaction may occur with topical application (Tominack & Spyker, 1987).

a) SENSORY NEURON CHANGES: Topical application of capsaicin to the cornea produced changes in the fine structures of the sensory neurons (Carpenter & Lynn, 1981).
b) ABRASIONS: Corneal abrasions were identified in 7 patients out of 30 (23%), by fluorescein staining following aerosol exposure to oleoresin capsicum (Watson et al, 1996). In a descriptive, retrospective review of 100 individuals exposed to aerosol pepper spray, 7 developed corneal abrasions. Based on this review, it could not be determined if the pepper spray compound, the carrier or propellant, or the patient rubbing their eyes produced the ocular effects observed (Brown et al, 2000).
c) EPITHELIAL DEFECT with STROMAL OPACITY: A woman was sprayed in the eyes with pepper spray during the course of her arrest and received no ocular irrigation for more than 9 hours. The right eye was asymptomatic. However, worsening ocular irritation in the left eye was noted at 24 hours and an initial ophthalmology exam revealed a visual acuity of 20/80, keratopathy, and an epithelial defect with moderate inflammation of the eye. Inflammation resolved over 2 weeks with supportive care, but the patient had a persistent stromal opacity with a corrected visual acuity of 20/40 (Epstein & Majmudar, 2001).
d) ANIMALS: A single subcutaneous injection of 12.5, 25, or 50 mg/kg of capsaicin led to changes in the cornea of the mouse and rat, with histologic findings characterized by a loss of nerve axons in the corneal epithelium (Shimizer et al, 1984).
e) According to a retrospective review of cases reported to the California Poison Control System between 2002 and 2011, 249 of 3671 (6.8%) cases reported pepper spray exposure in individuals 6 years of age or older who had severe outcomes warranting medical evaluation. Of the 249 patients, 134 patients (53.8%) reported persistent pain, blurred vision, foreign body sensation, discharge or exudate, and periorbital swelling. Twelve cases documented corneal abrasions (Kearney et al, 2014).

a) CASE REPORT: A boy who accidentally sprayed capsaicin into his eyes from a dog repellent experienced stinging, tearing, and erythema, which cleared by the following day (Grant & Schuman, 1993).
b) CASE SERIES: In a series of 81 patients who presented to the emergency department following aerosol exposure of oleoresin capsicum from law enforcement action, 45 (56%) developed ocular burning, 36 (44%) developed conjunctival injection, 32 (40%) developed erythema, 13 (16%) lacrimation and 7 (9%) developed corneal abrasion (Watson et al, 1996).

a) Touching the nasal mucosa after handling plants containing capsaicin may cause considerable irritation or pain.
b) Fumes from burned plants or capsaicin sprays are highly irritating (Morton, 1971; Collier & Fuller, 1984).
c) Topical application of capsaicin (75 mcg) to the human nasal mucosa was more potent than methacholine (50 mg) in inducing rhinorrhea (Geppetti et al, 1988).

a) CASE REPORT: An 8-month-old infant was hypotensive and acidotic with hypokalemia and seizures when he was presented for medical care. He had a 7-day history of cough and 3 days of diarrhea and vomiting. He had been treated with an infusion made from capsaicin powder (dose and duration not specified). The child died on the day of hospital admission. It is not clear to what extent his underlying illness as opposed to the capsaicin exposure contributed to the clinical presentation (Snyman et al, 2001).

a) CASE REPORT: A 25-year-old man, who had been taking oral cayenne pepper pills, for weight loss, once daily for 5 days prior to onset of symptoms, presented to the emergency department with a 2-hour history of severe chest pain, with the pain radiating to his left arm, neck, and jaw. An ECG showed ST segment elevation in leads II, III, and aVF, indicating an inferior wall acute myocardial infarction (AMI). The patient's troponin T concentration peaked at 4.6 ng/mL (normal less than 0.01 ng/mL). A coronary angiogram, performed 3 hours post-onset of chest pain, revealed patent coronary arteries. With supportive treatment, including administration of sublingual nitroglycerin, the patient's pain and ECG abnormalities resolved. The patient had no risk factors for coronary artery disease and denied the use of illicit substances, suggesting that the AMI was a result of coronary vasospasm secondary to capsaicin use (Sogut et al, 2012).

a) When injected into rats, an initial fall, transient rise, then a secondary fall in blood pressure was noted. Treatment with adrenoceptors or cholineceptors was ineffective (Donnerer & Lembeck, 1982; Toda et al, 1972).

a) Capsaicin vapors, especially from burning, may cause significant pulmonary irritation and prolonged cough (Snyman et al, 2001; Morton, 1971; Collier & Fuller, 1984).
b) Bronchospasm, independent of histamine or acetylcholine mechanism, can be created by placing capsaicin on human bronchial preparations in vitro. The effect is similar to what is seen with substance P (Lundberg et al, 1983).
c) CASE SERIES: Five patients presented to the emergency department with shortness of breath or wheezing after exposure to oleoresin capsicum spray (Watson et al, 1996).
d) According to a retrospective review of cases reported to the California Poison Control System between 2002 and 2011, 249 of 3671 (6.8%) cases reported pepper spray exposure in individuals 6 years of age or older who had severe outcomes warranting medical evaluation. Of the 249 patients, 79 patients (31.7%) reported shortness of breath, chest tightness, and wheezing. Ten cases documented wheezing and bronchospasm (Kearney et al, 2014).

a) CASE REPORT: A 32-year-old healthy male, corrections officer, was exposed to pepper spray (approximately 3 to 4 feet from the source) during training and developed persistent shortness of breath and an inability to exercise. Forty-eight hours after exposure, a posterior and lateral chest x-ray and a CT scan of the chest were consistent with a pneumomediastinum and pneumopericardium likely due to severe coughing which gradually resolved. Upon further examination 3 months later, pulmonary function studies and lung volumes were within normal limits, but the patient was noted to have high resistance which was consistent with mild airway dysfunction. The patient denied any history of reactive airway disease. The authors concluded that, in general, individuals with a history of reactive airway disease or COPD may be at risk to develop hypersensitivity following exposure, but further study was suggested (Miller & Skolnick, 2006).
b) CASE REPORT: A 47-year-old woman presented to an outpatient pulmonary clinic with a 9-month history of chronic respiratory symptoms, including episodic dyspnea and wheezing that occurred every 1 to 2 days and would last for 4 to 5 hours. Interview of the patient revealed that she had been exposed to high concentrations of oleoresin capsicum gas (capsaicin) for greater than 20 minutes, and subsequently developed right-sided pleuritic chest pain, dyspnea, and cough, progressing to episodic dyspnea and cough over the next several months. At the outpatient clinic, her pulmonary function tests and chest x-ray were normal, with no evidence of infiltrates or bronchial disease, although she did have a positive methacholine challenge test, with a greater than 20% reduction in her FEV1. She was prescribed a budesonide/formoterol combination inhaler and, two months later, reported improvement but continued to have episodic dyspnea. She also reported greater sensitivity to environmental irritants (eg, scents, perfumes, cigarette smoke). Her score was 43 on the chemical sensitivity scale for sensory hyperreactivity (score range 1 to 55; 43 or higher is considered a high score). It is suspected that the patient developed airway sensory hyperreactivity syndrome following intense exposure to capsaicin (Copeland & Nugent, 2013).

a) Capsaicin, when inhaled using a nebulizer which produced a 10(-7) concentration, increased the mean inspiratory flow by inducing more rapid, but not shallower breathing (Maxwell et al, 1987).

a) SMOKE EXPOSURE: The smoke of burning chilies is also an irritant.

a) Capsaicin renders the skin of humans and animals insensitive to various types of chemical pain stimuli (Bernstein et al, 1981).

a) CASE REPORT: An 8-month-old infant was hypotensive and acidotic with hypokalemia and seizures when he was presented for medical care. He had a 7-day history of cough and 3 days of diarrhea and vomiting. He had been treated with an infusion made from capsaicin powder (dose and duration not specified). The child died on the day of hospital admission. It is not clear to what extent his underlying illness as opposed to the capsaicin exposure contributed to the clinical presentation (Snyman et al, 2001).

a) Skin treated with capsaicin will have reduced flare (vasodilatation) and reduced heat sensitivity. There is some evidence that the damage may be long lasting, especially with chronic exposure (Carpenter & Lynn, 1981).

a) Administer beta2 adrenergic agonists. Consider use of inhaled ipratropium and systemic corticosteroids. Monitor peak expiratory flow rate, monitor for hypoxia and respiratory failure, and administer oxygen as necessary.

a) 2.5 to 5 milligrams diluted with 4 milliliters of 0.9% saline by nebulizer every 20 minutes for three doses. If incomplete response, administer 2.5 to 10 milligrams every 1 to 4 hours as needed OR administer 10 to 15 milligrams every hour by continuous nebulizer as needed. Consider adding ipratropium to the nebulized albuterol; DOSE: 0.5 milligram by nebulizer every 30 minutes for three doses then every 2 to 4 hours as needed, NOT administered as a single agent (National Heart,Lung,and Blood Institute, 2007).

a) 0.15 milligram/kilogram (minimum 2.5 milligrams) diluted with 4 milliliters of 0.9% saline by nebulizer every 20 minutes for three doses. If incomplete response administer 0.15 to 0.3 milligram/kilogram (maximum 10 milligrams) every 1 to 4 hours as needed OR administer 0.5 mg/kg/hr by continuous nebulizer as needed. Consider adding ipratropium to the nebulized albuterol; DOSE: 0.25 to 0.5 milligram by nebulizer every 20 minutes for three doses then every 2 to 4 hours as needed, NOT administered as a single agent (National Heart,Lung,and Blood Institute, 2007).

a) The incidence of adverse effects of beta2-agonists may be increased in older patients, particularly those with pre-existing ischemic heart disease (National Asthma Education and Prevention Program, 2007). Monitor for tachycardia, tremors.

a) Consider systemic corticosteroids in patients with significant bronchospasm. PREDNISONE: ADULT: 40 to 80 milligrams/day in 1 or 2 divided doses. CHILD: 1 to 2 milligrams/kilogram/day (maximum 60 mg) in 1 or 2 divided doses (National Heart,Lung,and Blood Institute, 2007).

a) One hand was placed in cool water; the other in vegetable oil for 75 minutes.
b) Pain was evaluated on a visual analog scale. Cool tap water gave relief more quickly, while vegetable oil provided longer lasting relief.
c) A mechanism of action has not been established.