Plant Poisoning, Phytophototoxins Clinical Presentation

  • Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Jan 7, 2010
 

History

The history is essential in making the diagnosis of phytophotodermatitis. A patient's employment history; eating and drinking habits; recreational activities; tanning habits, including the use of herbal tanning lotions and citrus hair lighteners; prescription and over-the-counter medications; and travel experience may all provide essential information to the health care provider.[1, 12, 13, 14, 15, 16, 17, 18, 19, 20, 9] Phytophotodermatitis (PPD) often occurs in linear and odd patterns, including "handprints."

  • A phototoxic reaction can result from contact with a specific plant via skin exposure, or less commonly, ingestion, followed by exposure to sunlight. The photos below show a reaction after exposure to a plant and sunlight. The second image is a close-up view of the rash. 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 vesiculaCloser clinical view of bizarre angulated vesicular streaks, which occurred after contact with a plant and ultraviolet light exposure.
  • Symptoms usually occur within 24-48 hours following sunlight exposure.
  • Symptoms are frequently described as an initial burning pain and erythema, followed by blistering. Blistering may occur within 10 minutes.
  • Pruritus is uncommon, distinguishing PPD from allergic phytodermatitis (eg, toxicodendron dermatitis).
  • The irregular "burns" and handmark patterns produced, often without a clear-cut history, have been mistaken for child abuse. A good history is essential in differentiating the two in children.[21, 22, 23, 24]
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Physical

  • A usually sharp demarcation between normal covered skin and abnormal exposed skin is observed. The color of lesions may vary depending on the individual's underlying skin tone and the degree of exposure.
  • Initial nonpruritic erythema of exposed areas. A "burst" of skin lesions may been seen after contact with squirted lime juice or with sprayed plant materials onto an individual's uncovered arms or legs while utilizing a "weed whacker". Photos below show a rash caused by lime juice and subsequent sunlight exposure. The second photo was taken at follow-up visit. A 26-year-old female airline flight attendant expoA 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 photo of the patient above dThe 2-month follow-up photo of the patient above demonstrates the potential postinflammatory pigmentation changes and scarring that may occur with severe blistering of phytophotodermatitis.
  • Development of edema, leading to vesicles, bullae, or both (usually within 24-72 h)
  • Possible desquamation
  • Resultant dense hyperpigmentation from melanocytic response
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Causes

Phytophotodermatitis (PPD) is induced by exposure to certain plants with subsequent exposure to sunlight. PPD can occur through ingestion of the plant or, more commonly, through topical contact.

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Contributor Information and Disclosures
Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM  Associate Professor, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Joseph Lydon, MD, PhD  Consulting Staff, Section of Emergency Medicine, Dartmouth-Hitchcock Medical Center

Disclosure: Nothing to disclose.

William H Shoff, MD, DTM&H  Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Glaxo Smith Kline None None; Glaxo Smith Kline Honoraria Speaking and teaching

Specialty Editor Board

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT  Associate Clinical Professor; Medical and Managing Director, South Texas Poison Center, Department of Surgery/Emergency Medicine and Toxicology, University of Texas Health Science Center at San Antonio

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Clinical Toxicologists, American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, Society for Academic Emergency Medicine, and Texas Medical Association

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Michael Hodgman, MD  Assistant Clinical Professor of Medicine, Department of Emergency Medicine, Bassett Healthcare

Michael Hodgman, MD is a member of the following medical societies: American College of Medical Toxicology, American College of Physicians, Medical Society of the State of New York, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

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 photo of the patient above 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.
 
 
 
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