|Phytophotodermatitis caused by lime|
Phytophotodermatitis, also known as Berloque dermatitis or margarita photodermatitis, is a cutaneous phototoxic inflammatory reaction resulting from contact with a light-sensitizing botanical agent followed by exposure to ultraviolet light (from the sun, for instance). Symptoms include erythema (with or without blistering) and delayed hyperpigmentation. A reaction may be elicited in any person who has been exposed to adequate amounts of both a photosensitizing agent and ultraviolet light. Phytophotodermatitis is not an immunologic response; no prior exposure to the photosensitizing agent is required.
The photosensitizing substances found in phototoxic plants belong to a class of chemical compounds called the furanocoumarins, which are activated by long-wavelength ultraviolet (UVA) light. The most toxic of these organic compounds are the linear furanocoumarins, so called since they exhibit a linear chemical structure. Bergapten and xanthotoxin (also known as methoxsalen), two linear furanocoumarins derived from psoralen, are invariably found in plants associated with phytophotodermatitis.
A reaction typically begins within 24 hours of exposure and peaks at 48–72 hours after exposure. Initially, the skin turns red and starts to itch and burn. Large blisters (or bulla) form within 48 hours. The blisters may leave black, brown, or purplish scars that can last for several years. This hyperpigmentation of the skin is caused by the production of melanin triggered by the furanocoumarins.
Although media reports have suggested that eye exposure to the sap can lead to temporary or permanent blindness, the risk of permanent blindness is not supported by existing research.
Plants associated with phytophotodermatitis mainly come from four plant families: the carrot family (Apiaceae), the citrus family (Rutaceae), the fig family (Moraceae), and the legume family (Fabaceae).
The carrot family Apiaceae (or Umbelliferae) is the main family of plants associated with phytophotodermatitis.
False Bishop's weed (Ammi majus), the world's major source of the linear furanocoumarin xanthotoxin, has been used since antiquity to treat vitiligo but accidental or inappropriate use of this plant can lead to phytophotodermatitis. Despite this danger, A. majus continues to be cultivated for its furanocoumarins, which are still used for the treatment of skin disease.
Numerous species in the Apiaceae family are cultivated as food products, some of which exhibit phototoxic effects. In particular, celery, parsnip, and parsley have been reported to cause phytophotodermatitis among agricultural workers, grocery workers, and other occupational food handlers.
A number of phototoxic plant species in the carrot family have become invasive species, including wild parsnip (Pastinaca sativa) and the tall hogweeds of the Heracleum genus, namely, Persian hogweed (Heracleum persicum), Sosnowsky's hogweed (Heracleum sosnowskyi), and giant hogweed (Heracleum mantegazzianum). In particular, the public health risks of giant hogweed are well known.
Other plant species in the Apiaceae family that are associated with phytophotodermatitis include the blister bush (Notobubon galbanum), cow parsley (Anthriscus sylvestris), wild carrot (Daucus carota), various species of the Angelica genus (e.g., Korean angelica Angelica gigas), and most (if not all) species of the Heracleum genus (esp. the tall invasive hogweeds and the cow parsnips Heracleum sphondylium and Heracleum maximum).
The citrus family Rutaceae is the second most widely distributed family of plants associated with phytophotodermatitis.
Numerous citrus fruits in the Rutaceae family exhibit phototoxic effects. Of these, perhaps the best known is lime. Phytophotodermatitis associated with limes is sometimes referred to as "lime disease," not to be confused with Lyme disease.
Other plant species in the Rutaceae family that are associated with phytophotodermatitis include the burning bush (Dictamnus albus), the common rue (Ruta graveolens) and other plants in the Ruta genus.
The first and best line of defense against phytophotodermatitis is to avoid contact with phototoxic substances in the first place:
- Avoid contact with the Apiaceae family of plants, citrus fruits, and other biological agents known to have phototoxic effects. Do not incinerate phototoxic plants and agents since this will serve to disperse the phototoxic substances more widely.
- In outdoor situations where contact with phototoxic plants is likely, wear long pants and a long-sleeve shirt. Wear gloves and protective eyewear before handling such plants.
- If protective clothing is not available, apply sunscreen to exposed areas. This will provide some measure of protection if contact is made.
- After an outdoor activity, take a shower or a bath as soon as possible. Wash your clothing and then wash your hands after handling the dirty clothes.
A second line of defense is to avoid sunlight, so as not to activate a phototoxic substance:
- If you come in contact with a phototoxic substance, immediately wash the affected area with soap and cold water, and avoid any further exposure to sunlight for at least 48 hours. Heat and moisture can worsen the skin reaction, which is why it’s important to wash the affected area with soap and cold water.
- Stay indoors, if possible. Be sure to avoid light shining through windows.
- If staying indoors is not an option, cover the affected area with sun protective clothing.
- In lieu of sun-protective clothing, apply sunscreen to the affected areas after washing.
Phytophotodermatitis is triggered by long wavelength ultraviolet light (called UVA) in the range of 320–380 nanometers, so the best sun-protective clothing and sunscreen products will block these wavelengths of UVA radiation.
In 2011, the U.S. Food and Drug Administration (FDA) established a "broad spectrum" test for determining a sunscreen product's UVA protection. Sunscreen products that pass the test are allowed to be labeled as "Broad Spectrum" sunscreens, which protect against both UVA and UVB rays.
There is no equivalent test or FDA-approved labeling for sun-protective clothing. Some clothing is labeled with an Ultraviolet Protection Factor (UPF) but test results from Consumer Reports suggest that UPF is an unreliable indicator of UV protection.
Many different topical and oral medications may be used to treat the inflammatory reaction of phytophotodermatitis. A dermatologist may also prescribe a bleaching cream to help treat the hyperpigmentation and return the skin pigmentation back to normal. If the patient does not receive treatment, the affected sites may develop permanent hyperpigmentation or hypopigmentation.
The photosensitizing effects of plants have been known since antiquity. In Egypt around 2000 B.C., the juice of Ammi majus "was rubbed on patches of vitiligo after which patients were encouraged to lie in the sun." This ancient practice acknowledged the hyperpigmentation effects now known to accompany phytophotodermatitis.
One of the earliest reports of plant-based dermatitis was given by Chaumton in 1815, who noted that the outer rind and root of cow parsnip (a common name for any Heracleum species of plant) contained an acrid sap sufficiently strong to inflame and ulcerate the skin. Similarly in 1887 Sornevin reported that Heracleum sphondylium caused dermatitis. However, neither of these early reports recognized the crucial role of ultraviolet radiation.
"Berloque dermatitis" (from the French word "berloque" meaning trinket or charm) is a term coined by Rosenthal in 1925 to describe the pendant-like streaks of pigmentation observed on the neck, face, and arms of patients. He was unaware that, in 1916, Freund had correctly attributed these pigmentation effects to the use of cologne water infused with bergamot oil, an essential oil now known to contain a significant amount of bergapten, a linear furanocoumarin that gets its name from the bergamot orange. Freund, however, did not appreciate the fact that ultraviolet light was required to produce the pigmentation effects.
In 1937, dermatitis from Heracleum mantegazzianum was reported by Miescher and Burckhardt who suspected the possibility of light sensitization. A few years later, Kuske confirmed this hypothesis. In 1942, Klaber introduced the term "phytophotodermatitis" to emphasize that both plants and light were required to affect a reaction.
Darrell Wilkinson, a British dermatologist, gave an accurate description of the disease in the 1950s. In 1961, Efremov reported 357 cases of phytophotodermatitis from Heracleum dulce (sweet cow parsnip). He "noted the requirement for sunlight in evoking the dermatitis since inunction of the juice of the plant without exposure to sunlight was harmless." Between 1962 and 1976, numerous reports of phytophotodermatitis from giant hogweed (Heracleum mantegazzianum) were reported. By 1980, the photosensitizing effects of various plant species had become well known (as evidenced by the comprehensive work of Mitchell and Rook).
- List of cutaneous conditions
- Photosensitivity in humans
- Stinging plant, plants with hairs that inject poisons
- James, William Daniel; Berger, Timothy G.; Elston, Dirk M., eds. (2006). Andrews' Diseases of the Skin: Clinical Dermatology. Saunders Elsevier. p. 32. ISBN 978-0-7216-2921-6.
- McGovern, Thomas W; Barkley, Theodore M (2000). "Botanical Dermatology". The Electronic Textbook of Dermatology. Internet Dermatology Society. Section Phytophotodermatitis. Retrieved August 11, 2018.
- Alikhan, Ali (March 4, 2016). "Berloque Dermatitis". Medscape. Retrieved August 9, 2018.
- Riahi, Ryan R.; Cohen, Philip R.; Robinson, Floyd W.; Gray, James M. (June 2009). "What Caused The Rash On This Man's Wrist And Hand?". The Dermatologist. 11 (6).
- Abramowitz, Alan I.; Resnik, Kenneth S.; Cohen, Kenneth R. (1993). "Margarita Photodermatitis". New England Journal of Medicine. 328 (12): 891. doi:10.1056/NEJM199303253281220. PMID 8441448.
- Baugh, William P (September 8, 2016). "Phytophotodermatitis". Medscape. Retrieved August 9, 2018.
- Solis, R. R.; Dotson, D. A.; Trizna, Z. (2000). "Phytophotodermatitis: A Sometimes Difficult Diagnosis". Archives of Family Medicine. 9 (10): 1195–1196. doi:10.1001/archfami.9.10.1195. PMID 11115230.
- "Giant Hogweed" (PDF). Peterborough, Ont.: Ministry of Natural Resources and Forestry, Government of Ontario. p. 2. Retrieved July 15, 2018.
- Barradell, R.; Addo, A.; McDonagh, A. J. G.; Cork, M. J.; Wales, J. K. H. (1993). "Phytophotodermatitis mimicking child abuse". European Journal of Pediatrics. 152 (4): 291–292. doi:10.1007/BF01956735. PMID 8482273.
- Kavli, G.; Volden, G. (1984). "Phytophotodermatitis". Photodermatol. 1 (2): 65–75. PMID 6397734.
- Alouani, I.; Fihmi, N.; Zizi, N.; Dikhaye, S. (2018). "Phytophotodermatitis following the use of Ammi Majus Linn (Bishop's weed) for vitiligo" (PDF). Our Dermatol. Online. 9 (1): 93–94. doi:10.7241/ourd.20181.29.
- "Plants For A Future: Ammi majus".
- Birmingham, D. J.; Key, M. M.; Tublich, G. E.; Perone, V. B. (1961). "Phototoxic bullae among celery harvesters". Arch Dermatol. 83 (1): 73–87. doi:10.1001/archderm.1961.01580070079008. Cited in McGovern and Barkley 2000.
- Centers for Disease Control (CDC) (January 11, 1985). "Phytophotodermatitis among Grocery Workers - Ohio". Morbidity and Mortality Weekly Report. 34 (1): 11–13. PMID 3155560.
- Berkley, S. F.; Hightower, A. W.; Beier, R. C.; Fleming, D. W.; Brokopp, C. D.; Ivie, G. W.; Broome, C. V. (1986). "Dermatitis in grocery workers associated with high natural concentrations of furanocoumarins in celery". Ann Intern Med. 105 (3): 351–355. PMID 2943201.
- Aberer, W. (1992). "Occupational dermatitis from organically grown parsnip (Pastinaca sativa L.)". Contact Dermatitis. 26 (1): 62. doi:10.1111/j.1600-0536.1992.tb00880.x. PMID 1534739.
- Lovell, C. R. (1993). Plants and the skin (1st ed.). Oxford: Blackwell Scientific Publications. Cited in McGovern and Barkley 2000.
- Lutchman, L.; Inyang, V.; Hodgkinson, D. (1999). "Phytophotodermatitis associated with parsnip picking". J. Accid. Emerg. Med. 16 (6): 453–454. doi:10.1136/emj.16.6.453. PMC 1343418. PMID 10572825.
- Averill, Kristine M.; Di'Tommaso, Antonio (2007). "Wild parsnip (Pastinaca sativa): A troublesome species of increasing concern" (PDF). Weed Technology. 21: 279–287. doi:10.1614/WT-05-186.1.
- Cain, N.; Darbyshire, S. J.; Francis, A.; Nurse, R. E.; Simard, M.-J. (2010). "The Biology of Canadian weeds. 144. Pastinaca sativa L." Can. J. Plant Sci. 90 (2): 217–240. doi:10.4141/CJPS09110.
- Booy, O.; Cock, M.; Eckstein, L.; Hansen, S. O.; Hattendorf, J.; Hüls, J.; Jahodová, S.; Krinke, L.; Marovoková, L.; Müllerová, J.; Nentwig, W.; Nielsen, C.; Otte, A.; Pergl, J.; Perglová, I.; Priekule, I.; Pusek, P.; Ravn, H. P.; Thiele, J.; Trybush, S.; Wittenberg, R. (2005). "The giant hogweed best practice manual: guidelines for the management and control of invasive weeds in Europe" (PDF). Hørsholm: Center for Skov, Landskab og Planlægning/Københavns Universitet. ISBN 87-7903-209-5. Retrieved September 1, 2018.
- MacDonald, F.; Anderson, H. (May 2012). "Giant Hogweed (Heracleum mantegazzianum): Best Management Practices in Ontario" (PDF). Ontario Invasive Plant Council, Peterborough, ON. Retrieved September 1, 2018.
- "Health Hazards & Safety Instructions for Giant Hogweed (with graphic photos)". New York State Department of Environmental Conservation. Retrieved September 3, 2018.
- Gross, T. P.; Ratner, L.; de Rodriguez, O.; Farrel, K. P.; Israel, E. (1987). "An outbreak of phototoxic dermatitis due to limes". Am J Epidemiol. 125 (3): 509–514. PMID 3812457.
- Kung, A. C.; Stephens, M. B.; Darling, T (2009). "Phytophotodermatitis: Bulla formation and hyperpigmentation during spring break" (PDF). Mil. Med. 174 (6): 657–661. PMID 19585784.
- Hankinson, Andrew; Lloyd, Benjamin; Alweis, Richard (2014). "Lime-induced phytophotodermatitis". J Community Hosp Intern Med Perspect. 4 (4). doi:10.3402/jchimp.v4.25090. PMID 25317269.
- de Almeida Junior, Hiram Larangeira; Sartori, Débora Sarzi; Jorge, Valéria Magalhães; Rocha, Nara Moreira; de Castro, Luis Antonio Suita (2016). "Phytophotodermatitis: A Review of Its Clinical and Pathogenic Aspects". Journal of Dermatological Research. 1 (3): 51–56. Retrieved August 13, 2018.
- "Lime Disease: How a Fruity Drink Can Give You a Rash". SciShow. July 24, 2017. Retrieved November 5, 2018.
- Weber, Ian C; Davis, Charles P; Greeson, David M (1999). "Phytophotodermatitis: The other 'lime' disease". The Journal of Emergency Medicine. 17 (2): 235–237. doi:10.1016/S0736-4679(98)00159-0. PMID 10195477.
- Wessner, D.; Hofmann, H.; Ring, J. (1999). "Phytophotodermatitis due to Ruta graveolens applied as protection against evil spells". Contact Dermatitis. 41 (4): 232. doi:10.1111/j.1600-0536.1999.tb06145.x. PMID 10515113.
- Furniss, Dominic; Adams, Titus (2007). "Herb of Grace: An Unusual Cause of Phytophotodermatitis Mimicking Burn Injury". Journal of Burn Care & Research. 28 (5): 767–769. doi:10.1097/BCR.0B013E318148CB82. PMID 17667834.
- Eickhorst, Kimberly; Deleo, Vincent; Csaposs, Joan (2007). "Rue the Herb: Ruta graveolens–Associated Phytophototoxicity". Dermatitis. 18 (1): 52–55. doi:10.2310/6620.2007.06033. PMID 17303046.
- Arias-Santiago, S. A.; Fernández-Pugnaire, M. A.; Almazán-Fernández, F. M.; Serrano-Falcón, C.; Serrano-Ortega, S. (2009). "Phytophotodermatitis due to Ruta graveolens prescribed for fibromyalgia". Rheumatology. 48 (11): 1401. doi:10.1093/rheumatology/kep234. PMID 19671699.
- Davis, Dawn (August 12, 2011). "Sun-related Skin Condition Triggered by Chemicals in Certain Plants, Fruits". Dermatology, Mayo Clinic. Retrieved August 8, 2018.
- Leonard, Jayne (August 19, 2017). "Phytophotodermatitis: When plants and light affect the skin". Medical News Today. Retrieved August 8, 2018.
- "FDA announces new requirements for over-the-counter (OTC) sunscreen products marketed in the U.S." U.S. Food and Drug Administration. June 11, 2011. Retrieved August 9, 2018.
- "Testing sun protective clothing". Consumer Reports. August 11, 2015. Retrieved August 9, 2018.
- Chaumton, F. P. (1815). Flore Med. Paris. 2: 32. Cited by Mitchell and Rook (1979), p. 692.
- Rosenthal, O. (1925). "Berloque dermatitis: Berliner Dermatologische". Dermatologische Zeitschrift. 42: 295. Cited in Alikhan 2016.
- Freund, E. (1916). "Uber bisher noch nicht beschriebene kunstliche Hautverfarbungen". Dermatol Wochenschrift. 63: 931–933. Cited in McGovern and Barkley 2000.
- Miescher, G.; Burckhardt, W. (1937). "Herakleum Dermatitis: Case Presentation". Schweizer Medizinische Wochenschriff. 67: 82. Cited by Mitchell and Rook (1979), p. 696.
- Kuske, H. "Experimental investigations on photodermatitis caused by plant juices". Archiv fur Dermatologie und syphilis. 178: 273. Cited by Mitchell and Rook (1979), p. 696.
- Kuske, H. "Percutaneous photosensitization by plant juices". Dermatologica (Basel). 82: 273. Cited by Mitchell and Rook (1979), p. 696.
- Klaber, R. (1942). "Phytophotodermatitis". Br. J. Dermatol. 54: 193–211. Cited by McGovern and Barkley, sec. Phytophotodermatitis.
- "Munks Roll Details for Peter Edward Darrell Sheldon Wilkinson". munksroll.rcplondon.ac.uk. Retrieved 2017-11-10.
- Efremov, A. I. "The Photodermatitis caused by Sweet Cow Parsnip (Heracleum dulce)". Vestn. Derm. Vener. (in Russian). 4: 64. Cited by Mitchell and Rook (1979), p. 693.
- Mitchell, John; Rook, Arthur (1979). Botanical Dermatology: Plants and Plant Products Injurious to the Skin. Vancouver: Greengrass. pp. 692–699.
|Wikimedia Commons has media related to Phytophotodermatitis.|