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Picture of the Month
Paul S. Bergeson, MD;
Jeffrey C. Weiss, MD
From the Division of General Pediatrics, Phoenix Children's Hospital, Phoenix, Ariz.
Arch Pediatr Adolesc Med. 2000;154:201-202.
TWO CHILDREN presented with skin lesions of different appearance but similar cause. Neither child had a history of lesions of this nature and neither had systemic symptoms. A 5-year-old girl was referred for evaluation of erythematous, vesicular, pruritic, and bullous skin lesions on her face, upper chest, abdomen, and extremities, which developed over 24 hours. The fluid in the bullae was clear. The skin covered by the top of her 2-piece bathing suit was spared. Two siblings had similar skin lesions that had developed during the same time span (Figure 1 and Figure 2). A 3-year-old boy presented with asymptomatic, macular, brownish skin lesions, predominantly on his arms, first noted on the day of referral (Figure 3 and Figure 4).
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Figure 1.
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Figure 2.
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Figure 3.
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Figure 4.
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Denouement and Discussion: Phytophotodermatitis
Figure 1 and Figure 2. The skin lesions on the trunk conform precisely to the borders of the bathing suit. Bullae and vesicles, some linear in arrangement, are set on an erythematous base. The history revealed that the girl and her siblings had eaten limes, the juice of which had run down onto the chest and abdomen. The children were exposed to sunlight.
Figure 3 and Figure 4. Hyperpigmented patches and macules are present on both arms. The skin lesions appeared shortly after harvesting ornamental oranges.
Phytophotodermatitis refers to a skin eruption that results from the interaction of radiant energy from the sun with photosensitizing compounds found in various plants. These agents that potentially produce phototoxic effects are present in many plant varieties, including several isomers of psoralens (furocoumarins). The psoralens form phototoxic compounds on exposure to UV-A radiation (wavelengths of 320-400 nm).1 The compounds cause direct damage to the DNA of epidermal cells, resulting in reactions that range from macular erythema or hyperpigmentation to blistering lesions, depending on the extent of exposure. The figures show the spectrum of skin reactions that may be seen.
CLINICAL MANIFESTATIONS
The acute phase of phytophotodermatitis is often characterized by erythematous plaques, vesicles, and bullae, much like a severe sunburn. Lesions may simply become erythematous or appear as hyperpigmented patches without a preceding erythematous phase. The shape of the lesions is often unusual, sometimes resembling streaks from dripping juices containing the phototoxic compounds. The hands and mouth are often extensively affected secondary to eating and handling. The unusual configuration of lesions is often a clue to the diagnosis. The skin eruptions may appear hours to days after exposure.
PLANTS ASSOCIATED WITH PHYTOPHOTODERMATITIS
The plants that are the most common causes of this dermatitis are limes, lemons, and celery. Natural grasses, carrots, oranges, parsley, parsnips, and several plants in the family Compositae, such as sagebrush, goldenrod, chrysanthemum, ragweed, and cocklebur, may also contain natural psoralens.2 Tobacco, figs, garlic, hot peppers, and hyacinth and daffodil bulbs are among the other offenders.
DIAGNOSIS AND TREATMENT
Phytophotodermatitis is a clinical diagnosis. The sunburnlike reactions with unusual configurations should suggest the diagnosis. A history of contact with one of the offending plants and subsequent sunlight exposure should be sought. The unusual nature of these skin lesions may suggest child abuse, scalding, cellulitis, and fungal infections.1, 3
There is no specific treatment for this reaction. In severe cases, analgesics, antihistamines for itching, and wet compresses may be used. Blistered areas should be kept clean to prevent secondary infection. The hyperpigmentation fades over time as it does in sunburned skin.
AUTHOR INFORMATION
Accepted for publication March 31, 1999.
Corresponding author: Paul S. Bergeson, MD, Phoenix Children's Hospital, 909 E Brill St, Phoenix, AZ 85006.
REFERENCES
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1. Goskowicz MO, Friedlander SF, Eichenfield LF. Endemic "lime" disease: phytophotodermatitis in San Diego county. Pediatrics. 1994;93:828-830.
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2. Juckett GV. Plant dermatitis: possible culprits go far beyond poison ivy. Postgrad Med. 1996;100:167-171.
3. Coffman K, Boyce WT, Hansen RC. Phytophotodermatitis simulating child abuse. AJDC. 1985;139:239-240.
SECTION EDITOR: WALTER W. TUNNESSEN, JR, MD
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