Phytophotodermatitis

Phytophotodermatitis

No Results

No Results

processing….

Phytophotodermatitis (PPD) is a cutaneous phototoxic inflammatory eruption resulting from contact with light-sensitizing botanical substances, also known as furanocoumarins, and long-wave ultraviolet A (UV-A, 320-380 nm) radiation. Psoralen is the particle that is active in furanocoumarins. [1] Furanocoumarins, present in some plants (eg, parsley, celery, carrots, limes), react using their parent compound, psoralen, with the UV radiation, which forms the eruptions on the skin. [2] The eruption usually begins approximately 24 hours after exposure and peaks at 48-72 hours. [3] The incidence rate is unknown. [1] More serious conditions should be ruled out. [1] The occurrence of the rash requires exposure to furanocoumarins and sunlight, it but also largely depends on the individual’s immune system. [4] The phototoxic result may be intensified by wet skin, sweating, and heat. The onset of the rash may be delayed and may not occur immediately after exposure to all of the elements. [5] Once the rash does occur, it may take weeks to resolve. [5]

Phytophotodermatitis typically manifests as a burning erythema that may subsequently blister. Postinflammatory hyperpigmentation lasting weeks to months may ensue (see the images below). In some patients, the preceding inflammatory reaction may be mild and go unrecognized by the patient. In this case, the patient presents with only pigmentary changes. Pain may be associated with the blister, resulting from necrosis of the affected epidermis. [4] The rash typically is nonpruritic, and if pruritus occurs, then further investigation into alternative diagnoses should be considered. [1]

See 11 Common Plants That Can Cause Dangerous Poisonings, a Critical Images slideshow, to help identify plant reactions and poisonings.

Also see Berloque Dermatitis and Drug-Induced Photosensitivity.

Cutaneous inflammation produced by plants can be separated into 4 groups based on their specific mechanism of action: urticarial dermatitis, irritant contact dermatitis, allergic contact dermatitis, and phototoxic dermatitis.

Phytophotodermatitis is a phototoxic reaction entirely independent of the immune system. In other words, phytophotodermatitis can occur in any individual, and prior sensitization or an intact immune system is not required. The ingredients needed to produce phytophotodermatitis include temporal exposure to both a photosensitizing substance, such as psoralens, and ultraviolet radiation. Furocoumarins are photosensitizing chemical components produced by certain plants and consist of psoralens, 5-methoxypsoralens, 8-methoxypsoralens, angelicin, bergaptol, and xanthotal.

The natural sunlight emission spectrum reaching the earth ranges from approximately 270-5000 nm. This electromagnetic radiation consists of photons with a reciprocal relationship between the wavelength and the energy of the photons. Only light that is absorbed into the skin can cause a photochemical reaction. Within the light spectra, UV-A (320-400 nm) is responsible for the vast majority of photoreactions resulting in phytophotodermatitis.

The wavelengths of ultraviolet light that most efficiently produce phytophotodermatitis lie within the UV-A range and have peak activity at 335 nm. When a photon with the appropriate wavelength strikes a furocoumarin, the energy is absorbed, raising this chemical to a triple excited state from the ground state. Upon return to the ground state, energy is released in the form of heat, fluorescence, and/or phosphorescence, and a photoproduct may form.

Two distinct photochemical reactions have been described in phytophotodermatitis, which occur independently from each other. A type I reaction occurs in the absence of oxygen, whereas a type II reaction occurs in the presence of oxygen. These photochemical reactions damage cell membranes and DNA and result in DNA interstrand cross-linking between the psoralen furan ring and the thymines or the cytosines of DNA. During the type I oxygen-independent reaction, the RNA and nuclear DNA become fastened to the exposed ultraviolet-activated furocoumarins. Likewise, the oxygen-dependent reactions result in cell membrane damage and edema from activated furocoumarins. This results in activation of arachidonic acid metabolic pathways and in cell death (sunburn cells and apoptotic keratinocytes). Clinically, erythema, blistering, epidermal necrosis, and eventual epidermal desquamation occur. See the image below.

A postinflammatory pigment alteration may follow the acute phase of this phototoxic reaction. This alteration occurs primarily by 2 mechanisms. First, melanin, which is normally found in the epidermis, “falls” into the dermis and is ingested by melanophages. Secondly, an increased number of functional melanocytes and melanosomes are distributed in the epidermis following phytophotodermatitis and also account for the hyperpigmentation. This hyperpigmentation may serve as a protective mechanism against further UV injury. Clinically, this corresponds with irregular hyperpigmentation (or occasionally hypopigmentation resulting in dyschromia) seen as the end stage of the phototoxic reaction.

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

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, [6] Rutaceae, [7] 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 [8]

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. [9]

The overall incidence of phytophotodermatitis is unknown, but it undoubtedly varies according to the population studied and is based on the risk of exposure to psoralen compounds. Because furocoumarins are found in a wide range of wild and domestic plants, a variety of patient groups may become exposed. An example of an international greenery known to produce phytophotodermatitis is Ficus carica, also known as a fig tree. This plant is often sought for the fruit it produces, as well as for analgesic folk medicine applications. Ficus pumila can be found worldwide, yet is native to China, Japan, and Taiwan.

Any race may be affected, but phytophotodermatitis is most easily recognized in fair-skinned patients.

Both sexes may be affected.

Any age may be affected, but note that phytophotodermatitis occurring on a child may be mistaken for child abuse. Classic examples include a handprint pattern on a child after exposure to a parent cooking with lime juice or a linear drip pattern on a child’s hands and arms after eating real juice ice pops.

The prognosis is good with identification and avoidance of the offending agent. Most commonly, phytophotodermatitis is a localized cutaneous phenomenon resulting initially in a burning sensation, which may be followed acutely by erythema and blistering. Eventually, the affected sites may desquamate and develop permanent hyperpigmentation or hypopigmentation. However, scarring is rare.

Reassure the patient that phytophotodermatitis is a self-limited problem that resolves with removal of the offending agent.

Harshman J, Quan Y, Hsiang D. Phytophotodermatitis: Rash with many faces. Can Fam Physician. 2017 Dec. 63 (12):938-940. [Medline].

Marcos LA, Kahler R. Phytophotodermatitis. Int J Infect Dis. 2015 Sep. 38:7-8. [Medline]. [Full Text].

Smith E, Kiss F, Porter RM, Anstey AV. A review of UVA-mediated photosensitivity disorders. Photochem Photobiol Sci. 2012 Jan. 11 (1):199-206. [Medline].

Smith LG, Kabhrel C. Phytophotodermatitis. Clin Pract Cases Emerg Med. 2017 May. 1 (2):146-147. [Medline].

Fitzpatrick JK, Kohlwes J. Lime-Induced Phytophotodermatitis. J Gen Intern Med. 2018 Jun. 33 (6):975. [Medline].

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

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. 1990 Nov. 7(2-4):199-208. [Medline].

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

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

Raam R, DeClerck B, Jhun P, Herbert M. Phytophotodermatitis: The Other “Lime” Disease. Ann Emerg Med. 2016 Apr. 67 (4):554-6. [Medline]. [Full Text].

Berkley SF, Hightower AW, Beier RC, et al. Dermatitis in grocery workers associated with high natural concentrations of furanocoumarins in celery. Ann Intern Med. 1986 Sep. 105(3):351-5. [Medline].

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

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

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

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

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. 2007 Jan. 56(1):84-7. [Medline].

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

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

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. 2007 Nov. 57(5 Suppl):S88-91. [Medline].

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

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

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

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

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

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

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 [8]

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

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.

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.

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.

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.

Natalie Ana Baugh California State University, Long Beach

Disclosure: Nothing to disclose.

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.

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: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.

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.

Phytophotodermatitis

Research & References of Phytophotodermatitis|A&C Accounting And Tax Services
Source