The many faces of phytophotodermatitis
Hiram Larangeira de Almeida Jr, Valeria Magalhães Jorge
Dermatology Online Journal 12 (7): 8

Catholic and Federal University of Pelotas, Brazil. hiramalmeidajr@hotmail.com

Abstract

Phytophotodermatitis is a common cutaneous phototoxic reaction produced by contact with a variety of plant substances, followed by sunlight exposure. Phytophotodermatitis can simulate child abuse , impetigo, superficial lymphangitis, and larva migrans. The most frequent presentation is hyperpigmentation of the dorsum of the hands, but there are other less common findings such as blisters or lesions mimicking solar lentigines and melasma.


Phytophotodermatitis is a common cutaneous phototoxic reaction. Contact with plant-derived phototoxic substances (furanocoumarins or psoralens) followed by sunlight exposure produces the clinical lesions [1, 2]. These phototoxic substances are found in various vegetable families (Umbilliferae, Moracea, Rutaceae, and Leguminous) [3, 4]. Exposure may occur during fruit and vegetable processing, hiking, jogging, or by the use of plant-derived medicines and cosmetics [3, 4, 5, 6, 7, 8, 9].

Phytophotodermatitis cases are seen worldwide. In the city of Pelotas (South Brazil), after telephone contact with local dermatologists during 2 consecutive summers, an incidence of 16 cases per 100,000 inhabitants per year was estimated. The most common cause in Pelotas is the Tahiti lemon.

The diagnosis of phytophotodermatitis is not always easily established; some cases can simulate child abuse, impetigo , superficial lymphangitis, or larva migrans [10, 11, 12].

In a prior study we demonstrated in rats that only the peel juice and not the fruit juice of lemons is associated with phytophotodermatitis [13], confirming a previous study in humans [14].


Figure 1 Figure 2

Figure 3 Figure 4

The most common feature of phytophotodermatitis is hyperpigmentation on the dorsum of the hands (Fig. 1). In more seriously affected cases, erythema and blisters may appear in the acute phase (Fig. 2). In the experimental model, exposure-time dependent epithelial degeneration and necrosis is demonstrated, which leads to the blister formation [13]. The hyperpigmentation may be in large areas (Fig. 1) or punctiform, simulating solar lentigines (Fig. 3). In such cases it may be that small drops of the peel juice are sprayed onto the skin surface during fruit handling. Bizarre hyperpigmented lesions may form depending on how the phototoxin drips over the skin surface (Fig. 4).


Figure 5 Figure 6

Figure 7

The dorsum of the hands are often the most common sites of both chemical exposure and sun exposure and hence are most frequently affected (Figs. 1 and 3), but sometimes the condition can appear differently. Some patients accidentally have contact with the plant materials on other body parts; some hours later they may notice the sudden appearance of a "burned" area (Fig. 5). During fruit or vegetable processing, contact may occur on the thighs (Fig. 6). A less common presentation of phytophotodermatitis is seen on the upper lip, when the psoralens reach the skin when the patient drinks the peel juice or bites the fruit (Fig. 7); this form may mimic melasma. In the cases shown, the plant phototoxins were from the Tahiti lemon.

Generalists and patients often do not suspect contact phototoxicity as the cause of such strange hyperpigmented lesions and blisters on sun-exposed skin. Patients must be instructed to handle with care vegetables that may induce phytophotodermatitis. Concubinal cases have been reported and small children have been affected through the contaminated hands of babysitters.

References

1. Stoner JG, Rasmussen JE. Plant dermatitis. J Am Acad Dermatol 1983; 9: 1-15. PubMed

2. Padilla HC. Fitofotodermatitis. Algunos aspectos fotobiológicos de los psoralenes. Med Cut ILA 1988; 16: 267 - 272. PubMed

3. Wagner AM, Wu JJ, Hansen RC, Nigg HN, Beiere RC. Bullous Phytophotodermatitis associated with high natural concentrations of furanocoumarins in limes. Am J Contact Dermat 2002; 13: 10-14. PubMed

4. Diógenes MJN, Matos FJA. Dermatite de Contato por Plantas. An Bras Dermatol 1999; 74: 629-634.

5. Finkelstein E, Afek U, Gross E, Aharoni N, Rosenberg L, Halevy S. An outbreak of phytophotodermatitis due to celery. J Dermatol 1994; 33: 116-118. PubMed

6. Seligman PJ, Mathias T, Malley MA, et al. Phytophotodermatitis from celery among grocery story workers. Arch Dermatol 1987; 123: 1478-1482. PubMed

7. Mateos F, Canals AG, Arboix ML. Fitofotodermatitis. An Esp Pedriatr 2000; 52: 72-73. PubMed

8. Watemberg N, Urkin Y, Witztum A. Phytophotodermatitis due to figs. Cutis 1991; 48:151-152. PubMed

9. Maso MJ, Ruszkowski AM, Bauerle J, Deleo V, Gasparro FP. Celery Phytophotodermatitis in a chef. Arch Dermatol 1991; 127: 912-913. PubMed

10. Tunget CL, Turchen SG, Manoguerra AS, Clark RF, Pudoff DE. Sunlight and the plant: a toxic Combination: severe phytophotodermatitis from Cneoridium dumosun. Cutis 1994; 54:400-402. PubMed

11. Ahmed I, Holmes RC. Phytophotodermatitis mimicking superficial lymphangitis. Br J Dermatol 2000; 142: 1047-1070. PubMed

12. Solis RR, Dotson DA, Trizna Z. Phytophotodermatits. A sometimes difficult diagnosis. Arch Fam Med 2000; 9:1195-1196. PubMed

13. Gonçalves NEL, de Almeida Jr. HL , Hallal EC, Amado M. Experimental phytophotodermatitis. Photodermatol Photoimmunol Photomed. 2005;21 :318-21 PubMed

14. Martins EC, Tomimori PK, Sampaio SAP. Fitofotodermatose experimental pelo limão Taiti. Med Cut ILA 1974; 5: 441-446. PubMed

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Title:

The many faces of phytophotodermatitis

Journal Issue:

Dermatology Online Journal, 12(7)

Author:

Jr, Hiram Larangeira de Almeida;
Jorge, Valeria Magalhães

Publication Date:

2006

Publication Info:

Dermatology Online Journal, UC Davis

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