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Phytophotodermatitis Clinical Presentation

  • Author: William P Baugh, MD; Chief Editor: William D James, MD  more...
 
Updated: Jul 24, 2014
 

History

The history is essential in making the correct diagnosis of phytophotodermatitis. The clinician must be aware that this entity exists and inquire about contact with fruits or plants. This is particularly true if the patient complains of a painful or burning sensation rather than pruritus (which is commonly associated with allergic contact dermatitis). The patient's hobbies, recreational activities, and/or occupation may give essential clues to the most likely culprits.

Phytophotodermatitis most commonly occurs in the spring and the summer when furocoumarins are at their highest concentration in plants and when UV exposure is greatest for patients. For instance, children playing outdoors may come in contact with meadow grass of the Umbelliferae family.

Agricultural workers may develop phytophotodermatitis when picking parsley (Cymopteris watsonii), parsnips (Pastinaca sativa), celery (Apium graveolens), and/or carrots (Daucus carota). The resulting photocutaneous reaction in this group has been called harvester's dermatitis and is primarily due to exposure to Umbellifers. Another report describes an outbreak of "strimmer rash" in several grounds operatives who had all undertaken grass-cutting duties. The affecting agent was likely giant hogweed, also from the Umbellifers.

Cneoridium dumosum is a plant found along the southwestern coastal United States to which hikers may be exposed, resulting in phytophotodermatitis. Patients are often attracted to this plant by its scented white flower and red berries.

Bartenders and grocers classically develop phytophotodermatitis due to exposure to limes and celery, respectively.[2, 3]

Several reports describe patients creating fig leaf decoctions to use as "tanning lotions" or "suntan promoters." Fig leaves (Ficus carica or Ficus benjamina) are either ground up, boiled, or mixed with oil and then applied on the skin.[4, 5] Patients reported having found these decoction recipes from magazines and/or friends.

One report describes a patient rubbing the juice of medicinal limes (Citrus hystrix) onto the skin as a treatment for insect bites and as an insect repellent, which subsequently resulted in phytophotodermatitis.

Another report describes a patient rubbing the juice of medicinal lime (C hystrix) onto the scalp hair to dye his hair. The juice trickled in between his fingers onto the back of his hands and down the arms to the elbows, where the patient developed phytophotodermatitis.

One case of iatrogenic phytophotodermatitis resulted from ingestion of an herbal remedy prescribed for chronic hand dermatitis.[6] Plant fragments contained in the herbal mix included extracts from Compositae, a member of the daisy family. No reports describe phytophotodermatitis after contact with members of the Compositae family. However, the action of boiling the plant mix may have possibly released high concentrations of intracellular furocoumarins.

One study assessed the potential of a small amount of psoralen in a normal diet to provoke phototoxicity in volunteers with skin types I and II. The study concluded that threshold erythema and phytophotodermatitis was unaffected by ingestion of this normal dietary amount of fresh parsnips.[7]

Another study reports on a 30-year-old man who trimmed the stems of a F pumila shrub while exposing his forearms, antecubital fossae, neck, and forehead. Within the following 3 days, the patient noticed eruptions appearing on the exposed areas. Six weeks following, the patient experienced confettilike hypomelanosis over the prior-unprotected areas of the skin. He was treated with clobetasol propionate cream.

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Physical

The primary skin lesion of phytophotodermatitis may range from delayed erythema (24-48 h) to frank blisters. The skin lesions are limited to the areas in contact with furocoumarin and with sunlight exposure. The primary lesion is often not seen by the physician because of the transient nature of the reaction. Rather, the patient presents with late skin changes that become apparent after 72 hours.

  • Late skin lesions
  • Bizarre inflammatory patterns and linear streaks of hyperpigmentation are key clues to diagnosing phytophotodermatitis. These patterns often result from brushing against a plant's stems or leaves while outdoors or from the liquid spread of lime juice over the hand or down the forearm. A handprint pattern from lime juice contact is not uncommon. See the images below.
    A 37-year-old white woman presented to the clinic A 37-year-old white woman presented to the clinic complaining of a rash on the medial part of her right thigh and left arm that was acquired after clearing some weeds in her yard. A phototoxic combination of sunlight and a psoralen-containing plant produced this bizarre linear vesicular eruption.
    Closer clinical view of bizarre angulated vesicula Closer clinical view of bizarre angulated vesicular streaks, which occurred after contact with a plant and ultraviolet light exposure.
    A 26-year-old female airline flight attendant expo A 26-year-old female airline flight attendant exposed to lime while serving drinks en route to the Caribbean. During the Caribbean layover, she had significant sun exposure. The combination of lime juice and sun exposure led to a drip-pattern blister formation on the dorsal forearm consistent with phytophotodermatitis. This picture clearly delineates the potential severity of phytophotodermatitis with extensive blister formation.
  • Furthermore, a buckshot spray over exposed surfaces is commonly seen in association with the use of string trimmers (weed-whackers) when unwanted weeds possessing furocoumarins are cleared from a field or a yard.
  • Skin distribution: Phytophotodermatitis is most commonly found on skin sites exposed to plants and sunlight; these include such areas as the arms and the legs, but it may occur anywhere.
  • Skin color: Skin color varies depending on the patient's underlying skin tone and the degree of the reaction. However, as previously stated, the acute phase of phytophotodermatitis manifests as erythema, and the end stage manifests as postinflammatory hyperpigmentation, as shown below.
    The 2-month follow-up picture of a patient with a The 2-month follow-up picture of a patient with a drip-pattern blister formation on the dorsal forearm demonstrates the potential postinflammatory pigmentation changes and scarring that may occur with severe blistering of phytophotodermatitis.
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Causes

The most common plant family to cause phytophotodermatitis is the Umbelliferae family. See the images below.

Queen Anne's lace, a member of the Umbelliferae fa Queen Anne's lace, a member of the Umbelliferae family of plants, is well known to produce a furocoumarin-induced phototoxic eruption.
Ficus. The common fig contains furocoumarins and s Ficus. The common fig contains furocoumarins and should be considered amidst the list of potential offending agents that cause phytophotodermatitis.

Phytophotodermatitis is most commonly caused by ingestion of or topical exposure to psoralens (furocoumarins). Psoralens have been isolated from at least 4 different plant families: Umbelliferae,[8] Rutaceae,[9] Moraceae, and Leguminosae.

Table. Common Causes of Phytophotodermatitis (Open Table in a new window)

Family Genus Species Common Names Main Compounds
Umbelliferae Amni majus Queen Anne's lace, Bishop's weed 8-methoxypsoralen (8-MOP), 5-methoxypsoralen (5-MOP), imperatorin
Heracleum sphondylium Cow parsnip 8-MOP, 5-MOP, imperatorin, phellopterin
Heracleum mantegazzianum Giant hogweed, Cartwheel flower 8-MOP, 5-MOP, imperatorin, phellopterin
Pastinaca sativa Parsnip 8-MOP, 5-MOP, imperatorin, isopimpinellin
Apium graveolens Celery Psoralens, 8-MOP, 5-MOP
Rutaceae Citrus bergamia Bergamot lime 5-MOP
Citrus maxima Zabon[10] 5-MOP
Dictamnus albus Gas plant, “Burning bush of Moses” 8-MOP, 5-MOP
Moracea Ficus carica Fig Psoralens, 5-MOP
Leguminosae Psoralea corylifolia Bavchi, Scurf pea Psoralens

Chart modified from Plants and the Skin. 1993:70-71.[11]

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Contributor Information and Disclosures
Author

William P Baugh, MD Assistant Clinical Professor of Dermatology, Western University of Health Sciences; Medical Director, Full Spectrum Dermatology; Consulting Staff, Department of Dermatology, St Jude Medical Center

William P Baugh, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Laser Medicine and Surgery, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Coauthor(s)

David Barnette, Jr, MD Voluntary Associate Clinical Professor, University of California San Diego School of Medicine

David Barnette, Jr, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology

Disclosure: Nothing to disclose.

Walter D Kucaba, DO Private Family Practice, Simpsonville, South Carolina

Walter D Kucaba, DO is a member of the following medical societies: Aerospace Medical Association, American Medical Association, American Osteopathic Association, Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Cynthia L Chen, DO, DO Intern, Pacific Hospital of Long Beach, California

Cynthia L Chen, DO, DO is a member of the following medical societies: American Osteopathic Association, California Medical Association, American Osteopathic College of Dermatology, Los Angeles County Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Society for Investigative Dermatology, Association of Professors of Dermatology, North American Hair Research Society

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Craig A Elmets, MD Professor and Chair, Department of Dermatology, Director, Chemoprevention Program Director, Comprehensive Cancer Center, UAB Skin Diseases Research Center, University of Alabama at Birmingham School of Medicine

Craig A Elmets, MD is a member of the following medical societies: American Academy of Dermatology, American Association of Immunologists, American College of Physicians, American Federation for Medical Research, Society for Investigative Dermatology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: University of Alabama at Birmingham; University of Alabama Health Services Foundation<br/>Serve(d) as a speaker or a member of a speakers bureau for: Ferndale Laboratories<br/>Received research grant from: NIH, Veterans Administration, California Grape Assn<br/>Received consulting fee from Astellas for review panel membership; Received salary from Massachusetts Medical Society for employment; Received salary from UpToDate for employment. for: Astellas.

References
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A 37-year-old white woman presented to the clinic complaining of a rash on the medial part of her right thigh and left arm that was acquired after clearing some weeds in her yard. A phototoxic combination of sunlight and a psoralen-containing plant produced this bizarre linear vesicular eruption.
Closer clinical view of bizarre angulated vesicular streaks, which occurred after contact with a plant and ultraviolet light exposure.
A 26-year-old female airline flight attendant exposed to lime while serving drinks en route to the Caribbean. During the Caribbean layover, she had significant sun exposure. The combination of lime juice and sun exposure led to a drip-pattern blister formation on the dorsal forearm consistent with phytophotodermatitis. This picture clearly delineates the potential severity of phytophotodermatitis with extensive blister formation.
The 2-month follow-up picture of a patient with a drip-pattern blister formation on the dorsal forearm demonstrates the potential postinflammatory pigmentation changes and scarring that may occur with severe blistering of phytophotodermatitis.
Close-up view of vesicular linear streaks with morphology suggestive of scattered foci of epidermal necrosis.
Queen Anne's lace, a member of the Umbelliferae family of plants, is well known to produce a furocoumarin-induced phototoxic eruption.
Ficus. The common fig contains furocoumarins and should be considered amidst the list of potential offending agents that cause phytophotodermatitis.
Table. Common Causes of Phytophotodermatitis
Family Genus Species Common Names Main Compounds
Umbelliferae Amni majus Queen Anne's lace, Bishop's weed 8-methoxypsoralen (8-MOP), 5-methoxypsoralen (5-MOP), imperatorin
Heracleum sphondylium Cow parsnip 8-MOP, 5-MOP, imperatorin, phellopterin
Heracleum mantegazzianum Giant hogweed, Cartwheel flower 8-MOP, 5-MOP, imperatorin, phellopterin
Pastinaca sativa Parsnip 8-MOP, 5-MOP, imperatorin, isopimpinellin
Apium graveolens Celery Psoralens, 8-MOP, 5-MOP
Rutaceae Citrus bergamia Bergamot lime 5-MOP
Citrus maxima Zabon[10] 5-MOP
Dictamnus albus Gas plant, “Burning bush of Moses” 8-MOP, 5-MOP
Moracea Ficus carica Fig Psoralens, 5-MOP
Leguminosae Psoralea corylifolia Bavchi, Scurf pea Psoralens
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