From Down Under to all over: Kava-induced cutaneous adverse reactions

By Warren R. Heymann, MD, FAAD
June 11, 2025
Vol. 7, No. 23

Firmly ensconced in my bucket-list travel time, I eagerly anticipate our trip to New Zealand, Tasmania, and mainland Australia in January 2025. (Editor’s note: This piece was written prior to the trip.) As a dermatologist, I may be excused for thinking about topics beyond koalas, Tasmanian devils, and the Sydney Opera House.

It has been 255 years since Captain James Cook and his crew reached Australia on their historic circumnavigation of the globe. Cook and the scientific staff on his first Pacific voyage are often credited as the first Europeans to observe kava ceremonies while on Tahiti in 1769. But more than 150 years earlier, while on Futuna Island, the Dutch explorers Jacob LeMaire and William Schouten described kava (the beverage) and the formal ceremonies surrounding its ritual consumption. Kava is the name of both a specific plant and the psychoactive beverage made from the plant. For millennia, Pacific Islanders have consumed kava in rituals and ceremonies.

According to Norton and Ruze, in their brilliant summation of the history of kava dermopathy, “Formal taxonomic description of kava [the plant] was completed by Georg Forster, a botanist on [Cook’s] second voyage. He prepared a proper Latin description and conferred the Linnean binomial Piper methysticum,* the “intoxicating pepper.” Forster was also the first to record the cutaneous effects of excessive consumption of kava. He wrote “cutis exarescere et in squamulas exfoliari” (“the skin dries up and exfoliates in little scales”).” [The * denotes how the citation may have been written]. (1) This commentary focuses on kava’s acute and chronic cutaneous effects.

There is an expanding worldwide use of supplements in complementary medicine. In traditional societies, kava (or “kava kava”) is typically consumed as a beverage for its relaxant, analgesic, and anxiolytic effects. (2) Despite the FDA’s conclusion, “After reviewing the available data and information, toxicology concludes that there is enough toxicological data that demonstrates that indiscriminate use of kava either as a ‘recreational’ or ‘relaxation’ beverage is not safe for human consumption,” (3) kava and kava derivatives are readily available, and kava consumption is legal in the United States.

The classic kava dermopathy is seen in people who consume large amounts of kava and is unlikely to be observed in those who consume in smaller amounts. Clinically, kava dermopathy presents as a reversible ichthyosiform eruption that may be associated with other adverse effects (lethargy, lymphocytopenia, and hepatic dysfunction). Among the Indigenous Australian kava-consuming population, kava dermopathy may be seen in up to 70% of heavy users compared to 0% of non-users. (4) Although the etiology of kava dermopathy is unknown, a hypothesis is that the lipid-soluble, pharmacologically-active kavalactones interfere with cholesterol metabolism, causing an acquired — but reversible — ichthyosis. (1) Shimoda et al. demonstrated that aqueous extracts of kava — but not purified kavalactones alone — are highly active in mast cells, resulting in the secretion of pro-inflammatory mediators. (5) Kava dermopathy resolves with abstinence. (1)

Dermatologists are more likely to encounter acute idiosyncratic rashes due to kava exposure than classic dose-related kava dermopathy. Although acute urticaria (6), patch test-positive contact dermatitis (7), and a dermatomyositis-like eruption (8) have been reported, it is the “sebotropic” eruptions that should alert clinicians to consider kava as the inciting culprit.

Jappe et al. described two patients — a 70-year-old man and a 52-year-old woman — who developed infiltrated papules and plaques on the face and trunk (and extremities on the woman) three weeks after kava kava was administered as an antidepressant. Biopsies demonstrated a lymphocytic infiltrate (CD8-positive in the man) surrounding the lower infundibulae and sebaceous glands with necrotic sebocytes. The authors suspected that this “allergic” reaction reflected the lipophilic profile of the kavapyrones. (9) Huynh et al. reported a 55-year-old man who developed an acneiform eruption with a cephalocaudad progression after consuming kava kava for three weeks. It resolved with discontinuation of kava kava and administration of prednisone and topical triamcinolone. (10)

Sebotropic kava-induced dermatoses may also be associated with variable systemic symptoms such as fever, facial edema, lymphadenopathy, myalgia, leukocytosis (neutrophilia, eosinophilia), and transaminitis. As noted previously, folliculocentric lymphocytic inflammation involving sebaceous glands with neutrophilic inflammation and focal necrosis of sebaceous lobules is observed; eosinophils may be noted. These cases responded rapidly to either prednisone or cyclosporine (in the patient described by Brown-Joel who demonstrated a minimal response to prednisone) and topical steroids. (11,12, 13)

Kava beverages are increasingly popular as a recreational drink in Western countries. Bian et al. “emphasize the urgent need for quality control and quality assurance of kava products, pharmacokinetics, absorption, distribution, metabolism, excretion, and foundational pharmacology. These are essential in order to inform research into the molecular targets, cellular mechanisms, and creative use of early stage human clinical trials for designer kava modalities to inform and guide the design and execution of future randomized placebo controlled trials to maximize kava’s clinical efficacy and to minimize its risks.” (14) With increasing use, dermatologists must recognize acute kava-induced adverse cutaneous reactions.

Point to Remember: As kava use increases, dermatologists should recognize the acute sebotropic eruption that may be accompanied by systemic symptoms. Classic kava dermopathy is a reversible acquired ichthyosis associated with heavy kava use.

Our expert’s viewpoint

Scott A. Norton, MD, MPH, MSc, FAAD
Adjunct Professor of Dermatology and Pediatrics
The George Washington University School of Medicine and Health Sciences

Dr. Heymann’s essay describes cutaneous side effects of drinking kava. As he explains, kava is the common name for both the specific plant and for the psychoactive beverage made from the plant. The kava plant is a woody shrub known scientifically as Piper methysticum (FIGURE A). It grows naturally on mountainous islands across the Central Pacific Basin, where it has contributed to traditional societies for centuries, if not millennia.

FIGURE A: A kava plant, Piper methysticum G. Forst. Note the characteristic heart-shaped leaves that are typical of plants in the black pepper plant family, Piperaceae (which is unrelated to capsicum or chile peppers).

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P. methysticum is native to Vanuatu, an archipelago in the southwest Pacific Basin, but ancient sea-going voyagers brought kava, along with roughly two dozen other useful plants, with them as they sailed to more distant lands. As the voyagers settled other island groups, such as Fiji, Tonga, Samoa, Tahiti, the Marquesas, and Hawai’i, they introduced sugar cane, coconut, breadfruit, taro, yams, sweet potatoes … and kava.

For many centuries, kava was consumed only during ritual events and almost exclusively by the royal and priestly classes. Indeed, on most islands, formal kava ceremonies of today are nearly identical to those of pre-European times (FIGURE B). Each ceremony is a highly choreographed, pro-social event that includes sacred gift exchanges, ancient chants, specialized preparation of the beverage with dedicated implements, selective participants, and a hierarchical manner of distributing the beverage.

FIGURE B1: Poulaho, King of the Friendly Islands drinking Kava. Tongatapu, Kingdom of Tonga (Friendly Islands). This is a close-up photograph of Dr. Norton’s framed and mounted original bookplate from Cook’s third voyage. The artist is John Webber, official illustrator on that voyage. In both B1 and B2, the red arrows point to the large traditional preparation bowl where kava is mixed. Purple arrows point to individual drinking cups, usually made from a coconut shell or a dried gourd.

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FIGURE B2: To honor Commemoration Day (1983), Fiji’s government issued a stamp showing the arrangements and actions of a modern-day formal ceremony.

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Kava contains several pharmacologically unique psychoactive compounds that induce an overall calming effect, as well as an unusual but reversible ataxia. Several components have transient depressant effects on spinal nerves, which cause a combined motor and proprioceptive ataxia. In a dose-dependent manner, after consuming sufficient amounts of kava, walking and other physical activities are impaired for several hours to several days. Thus, in traditional societies, only a small group of individuals, whose responsibilities did not include physical labor, were permitted to drink kava. That meant royalty and priests (male only) drank kava; farmers, fishermen, boat-makers, women, and other laborers did not.

Besides the desired psychoactive effects of kava, inveterate drinkers experienced a cutaneous side effect: a dose-dependent reversible ichthyosiform eruption, called kava dermopathy. Of course, back in the day, only men from the highest social strata, those who never engaged in physical labor, could drink enough to become ichthyotic.

The journals of Captain James Cook and other ship’s officers often described Pacific islanders as tall and splendidly built; handsome with good teeth and fine skin. But the journals also depict paramount chiefs on many islands as enfeebled and covered with a “leprous scurf,” due to kava’s ataxia and dermopathy respectively.

To the islanders of that era, kava dermopathy was probably not considered an adverse reaction. After all, in traditional societies, the ichthyotic changes meant the person belonged to an elite class that did not engage in physical labor, but instead were able to spend their days and nights drinking kava. The dermopathy indicated that a person belonged to the highest tiers of society.

FIGURE C: Kava dermopathy on lumbar region of an intermittently employed man who consumes large amounts of kava every evening in a deritualized manner. His acquired ichthyosis will resolve with abstinence from drinking kava.

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Nowadays among most Pacific societies, kava consumption has been largely deritualized. On some island groups, it is sold in mom-and-pop kava bars. People (including women) of any social class may now drink as much kava as they want — and get as ataxic and scaly as they please. Having kava dermopathy no longer signifies elite status; today any lay-about with a few coins can become as scaly as royalty of the past. (15)

Another aspect of kava’s deritualization is its wide availability in non-Pacific societies. Across the U.S., we find kava sold in kava bars, usually located in the “cool parts of town.” As Warren tells us, Westerners “typically consume [kava] … for its relaxant, analgesic, and anxiolytic effects.” Kava brings on a calm, relaxed state without the disinhibition and altered judgment associated with alcohol-based relaxants. These attributes make kava an attractive recreational compound

But we don’t see dose-dependent side effects in Westerners who drink kava. Instead, they get idiosyncratic reactions to kava, the simplest being a sebotropic eruption (and several types have been described). The worst idiosyncratic reaction to kava is fulminant (and often fatal) liver failure, which led many Western nations to ban importation of all kava products. (16)

In contrast, on traditional Pacific islands, we rarely encounter sebotropic eruptions or hepatotoxicity. Why is that? Several explanations have been offered. Traditional island kava is an aqueous (or salivary) extract of specific parts of the kava plant. In contrast, commercial preparations, sold for recreational use or as herbal medicine, are often made from the entire plant and the pharmacologic compounds are extracted with water, alcohol, and other solvents.

I have participated in kava ceremonies in the three ethnogeographic regions of the Pacific: in Polynesia (Hawai’i, where it is called ‘awa), in Micronesia (Pohnpei, where it is called sakau), and in Melanesia (Fiji, where it is called yaqona). I have no aversion to kava when it is prepared in a traditional manner and consumed in a ceremonial manner. It’s a beautiful ceremony and a rare honor to be invited to participate.

Besides, in the West, we have more than enough natural products with psychoactive properties (FIGURE D). Among indigenous populations, traditional psychoactive compounds are generally consumed in moderation and on ceremonial occasions (FIGURE B). But when these substances are consumed in a deritualized or recreational manner, norms no longer exist. In these situations, people can generally consume kava (or whatever the substance) in almost any amount. And kava’s serious adverse effects are almost exclusively associated with unfettered recreational use.

FIGURE D: Some of Dr. Norton’s accoutrements used in traditional drug delivery rituals: yerba mate bowl; tea pot; champagne flute; coffee pot; tea cup; kiddish cup; tobacco pipe; benjarong betel canister; Egyptian brass dallah cup for serving tea; beer stein.

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But, Warren, you probably won’t encounter kava in any form during your bucket-list trip to the Antipodes. The voyaging Polynesians who settled NZ either did not bring kava with them or they were unable to establish it in the temperate climes of NZ. (However, a similar appearing relative of kava, Piper excelsum, grows in NZ. The Maori call it kawakawa and it lacks psychoactive properties.) Furthermore, kava is not a traditional part of Australian societies either; it was introduced less than 50 years ago as a safer alternative to alcohol among indigenous peoples.

However, a dermatologic background will indeed help you understand the Antipodean fauna: koalas have sarcoptic mange and sexually transmitted chlamydial infections (17), and Tasmanian devils are afflicted with one of the strangest diseases imaginable, a directly implantable sarcoma known as devil facial tumour disease. (18)

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References

1. Norton SA, Ruze P. Kava dermopathy. J Am Acad Dermatol. 1994 Jul;31(1):89-97. doi: 10.1016/s0190-9622(94)70142-3. PMID: 8021378.

2. Huynh JC, Asgari MM, Moore MM. Sebotropic eruption associated with use of oral kava kava supplement. Clin Exp Dermatol. 2014 Oct;39(7):816-8. doi: 10.1111/ced.12439. PMID: 25214405.

3. https://www.fda.gov/media/169556/download

4. Heyes C, Tait C, Toholka R, Gebauer K. Non-infectious skin disease in Indigenous Australians. Australas J Dermatol. 2014 Aug;55(3):176-84. doi: 10.1111/ajd.12106. Epub 2013 Oct 8. PMID: 25117159.

5. Shimoda LM, Park C, Stokes AJ, Gomes HH, Turner H. Pacific island 'Awa (Kava) extracts, but not isolated kavalactones, promote proinflammatory responses in model mast cells. Phytother Res. 2012 Dec;26(12):1934-41. doi: 10.1002/ptr.4652. Epub 2012 Apr 4. PMID: 22473598; PMCID: PMC3773481.

6. Grace R. Kava-induced urticaria. J Am Acad Dermatol. 2005 Nov;53(5):906. doi: 10.1016/j.jaad.2005.04.068. PMID: 16243159.

7. Schmidt P, Boehncke WH. Delayed-type hypersensitivity reaction to kava-kava extract. Contact Dermatitis. 2000 Jun;42(6):363-4. PMID: 10871112.

8. Guro-Razuman S, Anand P, Hu Q, Mir R. Dermatomyositis-like illness following kava-kava ingestion. J Clin Rheumatol. 1999 Dec;5(6):342-5. doi: 10.1097/00124743-199912000-00008. PMID: 19078427.

9. Jappe U, Franke I, Reinhold D, Gollnick HP. Sebotropic drug reaction resulting from kava-kava extract therapy: a new entity? J Am Acad Dermatol. 1998 Jan;38(1):104-6. doi: 10.1016/s0190-9622(98)70547-x. PMID: 9448214.

10. Huynh JC, Asgari MM, Moore MM. Sebotropic eruption associated with use of oral kava kava supplement. Clin Exp Dermatol. 2014 Oct;39(7):816-8. doi: 10.1111/ced.12439. PMID: 25214405.

11. Brown-Joel ZO, Colleran ES, Stone MS. Inflammatory sebotropic reaction associated with kava kava ingestion. JAAD Case Rep. 2018 Apr 30;4(5):437-439. doi: 10.1016/j.jdcr.2017.12.011. PMID: 29984274; PMCID: PMC6031569.

12. Rzepecki AK, Wald J, Amin B, Leung E, Choi E, Balagula Y. Kava-induced acute cutaneous toxicity: An increasingly recognized characteristic clinicohistologic pattern. JAAD Case Rep. 2018 Nov 10;4(10):1037-1038. doi: 10.1016/j.jdcr.2018.08.011. PMID: 30456280; PMCID: PMC6232697.

13. du Plessis Nisbet J, Xie D, Thompson R, Wark K, Lamrock E, Scurry J. Kava-induced dermatitis: A detailed histopathological analysis. Australas J Dermatol. 2024 Sep;65(6):520-523. doi: 10.1111/ajd.14305. PMID: 38764392.

14. Bian T, Corral P, Wang Y, Botello J, Kingston R, Daniels T, Salloum RG, Johnston E, Huo Z, Lu J, Liu AC, Xing C. Kava as a Clinical Nutrient: Promises and Challenges. Nutrients. 2020 Oct 5;12(10):3044. doi: 10.3390/nu12103044. PMID: 33027883; PMCID: PMC7600512.

15. Urquhart B, Thomson N. Review of the misuse of kava among Indigenous Australians. Australian Indigenous HealthInfoNet. Sep;65(6):520-523. doi: 10.1111/ajd.14305. PMID: 38764392. http://www.healthinfonet.ecu.edu.au/kava_review (Accessed 17 Dec 2024)

16. 21 November 2017 EMA/HMPC/450589/2016 Committee on Herbal Medicinal Products (HMPC) Assessment report on Piper methysticum G. Forst., rhizome https://www.ema.europa.eu/en/documents/herbal-report/final-assessment-report-piper-methysticum-g-forst-rhizoma_en.pdf

17. Speight KN, Whiteley PL, Woolford L, Duignan PJ, Bacci B, Lathe S, Boardman W, Scheelings TF, Funnell O, Underwood G, Stevenson MA. Outbreaks of sarcoptic mange in free-ranging koala populations in Victoria and South Australia: a case series. Aust Vet J. 2017 Jul;95(7):244-249. doi: 10.1111/avj.12598. PMID: 28653387.

18. Welsh E, Updyke EA, Hamede R. Tasmanian devil facial tumor disease: sympathy for the devil. https://thispodcastwillkillyou.com/wp-content/uploads/2024/08/TPWKY-Episode-147-Devil-Tumor-Facial-Disease.pdf Accessed 15 Dec 2024.

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