eMedicine Specialties > Dermatology > Photo-Related Diseases

Phytophotodermatitis: Differential Diagnoses & Workup

Author: William P Baugh, MD, Assistant Clinical Professor of Dermatology, University of California Irvine School of Medicine and Western School of Medicine; Medical Director, Full Spectrum Dermatology; Consulting Staff, Department of Dermatology, St Jude Medical Center
Coauthor(s): David Barnette, Jr, MD, Chief of Dermatopathology, Departments of Internal Medicine and Dermatology, Naval Medical Center at San Diego; Walter D Kucaba, DO, Private Family Practice, Simpsonville, South Carolina; Cynthia L Chen, Western University of Health Sciences College of Osteopathic Medicine of the Pacific
Contributor Information and Disclosures

Updated: Oct 16, 2009

Differential Diagnoses

Contact Dermatitis, Allergic
Porphyria Cutanea Tarda
Contact Dermatitis, Irritant
Thermal Burns
Drug-Induced Bullous Disorders
Herpes Simplex
Jellyfish Stings

Other Problems to Be Considered

Child abuse11,12,13  
Cutaneous larva migrans 
Factitious dermatitis
Folk medicine14
Herpes simplex13
Marine envenomations15
Phototoxic eruption 
Phototoxic drug reaction
Straw mite or grocer's mite dermatitis
Superficial lymphangitis16  
Sunburn
Thermal burn17

Workup

Laboratory Studies

  • Phytophotodermatitis (PPD) is a clinical diagnosis. All laboratory data obtained are used to support the diagnosis and to exclude other diseases in the differential diagnosis.
  • Serum psoralen levels may be checked if unknown ingestion of psoralens is suspected.
  • Porphyrin levels may be obtained to rule out porphyria cutanea tarda.
  • If the clinical picture does not clearly distinguish between photoallergic and phototoxic dermatitis, performing a photopatch test may be prudent. The photopatch test should include testing for sunscreens because they may be a cause of allergic contact dermatitis associated with sun exposure.

Procedures

  • A skin biopsy may be performed to determine the clinical diagnosis if it remains in question and to help distinguish between allergic contact, photoallergic, and photodrug reactions.

Histologic Findings

Classic histopathologic features of phytophotodermatitis include the following:

Epidermal hyperkeratosis, with or without parakeratosis, is observed. Scattered necrotic keratinocytes (apoptotic cells) are found in the epidermis. Sunburn cells (cells with pyknotic nuclei, increased volume, and pale staining cytoplasm) are also found in the epidermis. Slight spongiosis is observed in the epidermis. Minimal inflammatory cell infiltrate consisting of neutrophils (predominant cell type early on), lymphocytes (less common), and macrophages and melanophages (late) is present. Subepidermal blistering and extravasation of erythrocytes may or may not be present. Pigment incontinence with melanophages is observed in the papillary dermis. The dermis shows some edema and enlargement of vascular endothelial cells.

Both light microscopy and transmission electron microscopy in animal models show keratinocyte necrosis and vacuolization within 24 hours. Within 48 hours, intraepidermal and subepidermal blistering is visible.18,19

More on Phytophotodermatitis

Overview: Phytophotodermatitis
Differential Diagnoses & Workup: Phytophotodermatitis
Treatment & Medication: Phytophotodermatitis
Follow-up: Phytophotodermatitis
Multimedia: Phytophotodermatitis
References
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References

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  2. Maso MJ, Ruszkowski AM, Bauerle J, DeLeo VA, Gasparro FP. Celery phytophotodermatitis in a chef. Arch Dermatol. Jun 1991;127(6):912-3. [Medline].

  3. Bassioukas K, Stergiopoulou C, Hatzis J. Erythrodermic phytophotodermatitis after application of aqueous fig-leaf extract as an artificial suntan promoter and sunbathing. Contact Dermatitis. Aug 2004;51(2):94-5. [Medline].

  4. Bollero D, Stella M, Rivolin A, Cassano P, Risso D, Vanzetti M. Fig leaf tanning lotion and sun-related burns: case reports. Burns. Nov 2001;27(7):777-9. [Medline].

  5. Moloney FJ, Parnell J, Buckley CC. Iatrogenic phytophotodermatitis resulting from herbal treatment of an allergic contact dermatitis. Clin Exp Dermatol. Jan 2006;31(1):39-41. [Medline].

  6. Beattie PE, Wilkie MJ, Smith G, Ferguson J, Ibbotson SH. Can dietary furanocoumarin ingestion enhance the erythemal response during high-dose UVA1 therapy?. J Am Acad Dermatol. Jan 2007;56(1):84-7. [Medline].

  7. Kavli G, Volden G, Raa J. Accidental induction of photocontact allergy to Heracleum laciniatum. Acta Derm Venereol. 1982;62(5):435-8. [Medline].

  8. Morlière P, Hüppe G, Averbeck D, Young AR, Santus R, Dubertret L. In vitro photostability and photosensitizing properties of bergamot oil. Effects of a cinnamate sunscreen. J Photochem Photobiol B. Nov 1990;7(2-4):199-208. [Medline].

  9. Izumi AK, Dawson KL. Zabon phytophotodermatitis: first case reports due to Citrus maxima. J Am Acad Dermatol. May 2002;46(5 Suppl):S146-7. [Medline].

  10. Lovell CR. Plants and the Skin. London, England: Blackwell Science; 1993:64-95.

  11. Coffman K, Boyce WT, Hansen RC. Phytophotodermatitis simulating child abuse. Am J Dis Child. Mar 1985;139(3):239-40. [Medline].

  12. Kos L, Shwayder T. Cutaneous manifestations of child abuse. Pediatr Dermatol. Jul-Aug 2006;23(4):311-20. [Medline].

  13. Carlsen K, Weismann K. Phytophotodermatitis in 19 children admitted to hospital and their differential diagnoses: Child abuse and herpes simplex virus infection. J Am Acad Dermatol. Nov 2007;57(5 Suppl):S88-91. [Medline].

  14. Koh D, Ong CN. Phytophotodermatitis due to the application of citrus hystrix as a folk remedy. Br J Dermatol. Apr 1999;140(4):737-8. [Medline].

  15. Burnett JW, Nguyen TV. Phytophotodermatitis: differentiation from jellyfish stings. Australas J Dermatol. 1989;30(2):101-2. [Medline].

  16. Ahmed I, Charles-Holmes R. Phytophotodermatitis mimicking superficial lymphangitis. Br J Dermatol. May 2000;142(5):1069. [Medline].

  17. Tunget CL, Turchen SG, Manoguerra AS, Clark RF, Pudoff DE. Sunlight and the plant: a toxic combination: severe phytophotodermatitis from Cneoridium dumosum. Cutis. Dec 1994;54(6):400-2. [Medline].

  18. Almeida HL Jr, Sotto MN, Castro LA, Rocha NM. Transmission electron microscopy of the preclinical phase of experimental phytophotodermatitis. Clinics (Sao Paulo). Jun 2008;63(3):371-4. [Medline].

  19. Jorge VM, de Almeida HL Jr, Amado M. Serial light microscopy of experimental phytophotodermatitis in animal model. J Cutan Pathol. Mar 2009;36(3):338-41. [Medline].

  20. Bensasson RV, Land EJ, Salet C. Triplet excited state of furocoumarins: reaction with nucleic acid bases and amino acids. Photochem Photobiol. Mar 1978;27(3):273-80. [Medline].

  21. Furniss D, Adams T. Herb of grace: an unusual cause of phytophotodermatitis mimicking burn injury. J Burn Care Res. Sep-Oct 2007;28(5):767-9. [Medline].

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  24. Musajo L, Rodighiero G. Studies on the photo-C4-cyclo-addition reactions between skin-photosensitizing furocoumarins and nucleic acids. Photochem Photobiol. Jan 1970;11(1):27-35. [Medline].

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  26. Ozdamar E, Ozbek S, Akin S. An unusual cause of burn injury: fig leaf decoction used as a remedy for a dermatitis of unknown etiology. J Burn Care Rehabil. Jul-Aug 2003;24(4):229-33; discussion 228. [Medline].

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  28. Santucci B, Picardo M. Occupational contact dermatitis to plants. Clin Dermatol. Apr-Jun 1992;10(2):157-65. [Medline].

  29. Stoner JG, Rasmussen JE. Plant dermatitis. J Am Acad Dermatol. Jul 1983;9(1):1-15. [Medline].

  30. 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. Mar 2002;13(1):10-4. [Medline].

  31. Wang L, Sterling B, Don P. Berloque dermatitis induced by "Florida water". Cutis. Jul 2002;70(1):29-30. [Medline].

  32. Wynn P, Bell S. Phytophotodermatitis in grounds operatives. Occup Med (Lond). Aug 2005;55(5):393-5. [Medline].

  33. Young AR, Magnus IA. An action spectrum for 8-MOP induced sunburn cells in mammalian epidermis. Br J Dermatol. May 1981;104(5):541-8. [Medline].

  34. Zaynoun ST, Aftimos BG, Abi Ali L, Tenekjian KK, Khalidi U, Kurban AK. Ficus carica; isolation and quantification of the photoactive components. Contact Dermatitis. Jul 1984;11(1):21-5. [Medline].

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Further Reading

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Keywords

phytophotodermatitis PPD, phototoxic reaction, urticarial dermatitis, irritant contact dermatitis, allergic contact dermatitis, phototoxic dermatitis, psoralens, furocoumarins, Umbelliferae, Rutaceae, Moraceae, Leguminosae

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Contributor Information and Disclosures

Author

William P Baugh, MD, Assistant Clinical Professor of Dermatology, University of California Irvine School of Medicine and Western School of Medicine; 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, and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

Coauthor(s)

David Barnette, Jr, MD, Chief of Dermatopathology, Departments of Internal Medicine and Dermatology, Naval Medical Center at San Diego
David Barnette, Jr, MD is a member of the following medical societies: American Academy of Dermatology and 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, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Cynthia L Chen, Western University of Health Sciences College of Osteopathic Medicine of the Pacific
Disclosure: Nothing to disclose.

Medical Editor

Craig A Elmets, MD, Director of Dermatology, Departments of Dermatology, Pathology, and Environmental Health Sciences; Professor, The Kirklin Clinic, University of Alabama at Birmingham
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, and Society for Investigative Dermatology
Disclosure: Palomar Medical Technologies Stock None; Amgen Consulting fee Review panel membership; Astellas Consulting fee Review panel membership; Massachusetts Medical Society Salary Employment; Abbott Laboratories Grant/research funds Independent contractor

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University 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, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey J Miller, MD, Associate Professor of Dermatology, Penn State University College of Medicine; Staff Dermatologist, Penn 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, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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