Clinical and immunologic features of systemic contact dermatitis from ingestion of Rhus (Toxicodendron)

A comprehensive review of medicinal Toxicodendron (Anacardiaceae): Botany, traditional uses, phytochemistry and pharmacology

ETHNOPHARMACOLOGICAL RELEVANCE

Comprising of about 30 species, the genus Toxicodendron (Anacardiaceae) are mainly distributed in East Asia and North America. Among them, 13 species have been traditionally used as folk medicines in Asia and other parts of the world to treat blood diseases, abnormal bleeding, skin diseases, gastrointestinal diseases, liver diseases, bone injury, lung diseases, neurological diseases, cardiovascular diseases, tonic, cancer, eye diseases, menstrual irregularities, inflammation, rheumatism, diabetes mellitus, rattlesnake bite, internal parasites, contraceptive, vomiting and diarrhea.

AIM OF THE STUDY

To date, no comprehensive review on Toxicodendron has been published and the scientific basis of the traditional medicinal benefits of Toxicodendron have been less reported. Therefore, this review aims to provide a reference for further research and development on medicinal purpose of Toxicodendron by summarizing the works (from 1980 to 2023), and focusing on its botany, traditional uses, phytochemistry and pharmacology.

MATERIALS AND METHODS

The names of the species were from The Plant List Database (http://www.theplantlist.org), World Flora Online (http://www.worldfloraonline.org), Catalogue of Life Database (https://www.catalogueoflife.org/) and Plants for A Future Database (https://pfaf.org/user/Default.aspx). And the search terms "Toxicodendron" and "the names of 31 species and their synonyms" were used to search for information from electronic databases such as Web of Science, Scopus, Google Scholar, Science Direct, PubMed, Baidu Scholar, Springer, and Wiley Online Library. Moreover, PhD and MSc dissertations were also used to support this work.

RESULTS

These species on Toxicodendron are widely used in folkloric medicine and modern pharmacological activities. So far, approximately 238 compounds, mainly phenolic acids and their derivatives, urushiols, flavonoids and terpenoids, are extracted and isolated from Toxicodendron plants, commonly, T. trichocarpum, T. vernicifluum, T. succedaneum, and T. radicans. Among them, phenolic acids and flavonoids are the main compound classes that show pharmacological activities in Toxicodendron plants both in vitro and in vivo. Furthermore, the extracts and single compounds of these species show a wide range of activities, such as antioxidant, antibacterial, anti-inflammatory, anti-tumor, liver protection, fat reduction, nerve protection, and treatment of blood diseases.

CONCLUSIONS

Selected species of Toxicodendron have been used as herbal medicines in the Southeast Asian for a long time. Furthermore, some bioactive constituents have been identified from them, so plants in this genus may be potential new drugs. The existing research on Toxicodendron has been reviewed, and the phytochemistry and pharmacology provide theoretical basis for some of the traditional medicinal uses. Therefore, in this review, the traditional medicinal, phytochemical and modern pharmacology of Toxicodendron plants are summarized to help future researchers to find new drug leads or to get a better understanding of structure-activity relationships.

A Case Report of Necrotizing Eosinophilic Folliculitis Occurring After Rhus Ingestion

Necrotizing eosinophilic folliculitis is known as a rare variant of eosinophilic folliculitis (EF). It differs from classic EF because of its necrotizing ulcerative clinical course. We report a case of necrotizing eosinophilic folliculitis accompanied by pathergic phenomenon that may be the result of a delayed type hypersensitivity reaction occurring after Rhus consumption. Painful pyodermic plaques developed in a 48-year-old man, over a 5-day period, which was associated with facial edema. The lesions appeared 2 days after ingestion of Rhus. His face showed multiple painful pruritic papules that coalesced into crusted plaque accompanied by hemorrhagic eschars. At the periphery of the plaques, multiple erythematous papules and pustules were noticed. Prominent tissue eosinophilia was noticed from the skin biopsy samples. Also, there were areas of follicular mucinosis and eosinophilic folliculitis as well as hemorrhagic scale crust over the surface. Based on the clinical and histologic findings, the patient was diagnosed as necrotizing eosinophilic folliculitis occurring after Rhus ingestion. The lesions rapidly cleared after starting treatment with systemic steroid and dapsone. Clinicians should be aware that necrotizing eosinophilic folliculitis may occur after Rhus contact or consumption, in order to diagnose and treat patients promptly and reduce patient discomfort and skin scarring.

Systemic Contact Dermatitis: The Routes of Allergen Entry

Systemic contact dermatitis (SCD) is a generalized reactivation of type IV hypersensitivity skin diseases in individuals with previous sensitization after a contact allergen is administered systemically. Patients with SCD may consider their dermatitis unpredictable and recalcitrant since the causative allergens are difficult to find. If a patient has a pattern of dermatitis suggestive of SCD but fails to improve with conventional treatment, SCD should be taken into consideration. If doctors are not familiar with the presentations of SCD and the possible routes of allergen sensitization and exposure, the diagnosis of SCD may be delayed. In this work, we summarized all of the routes through which allergens can enter the body and cause SCD, including oral intake, local contact (through skin, inhalation, nasal spray and anal application), implants, and other iatrogenic or invasive routes (intravenous, intramuscular, intraarticular, and intravesicular). This will provide a comprehensive reference for the clinicians to identify the culprit of SCD.

Systemic contact dermatitis induced by Rhus allergens in Korea: exercising caution in the consumption of this nutritious food

Systemic contact dermatitis (SCD) develops when a person who was previously sensitized to an allergen is exposed to the same allergen via the systemic route. In East Asia, the use of lacquer for polishing furniture is common and a part of the traditional culture. Contact exposure to tableware polished with Rhus lacquer may lead to sensitization. In Korea, SCD is commonly observed after systemic exposure to Rhus, a nutritious food item consumed because of the common belief of it improving the immune system. In this study, we reviewed the medical records of 21 Korean patients with SCD caused by Rhus ingestion. We found that the most significant epidemiological factor for SCD was the season of the year. Furthermore, 66.67% of the patients presented with leucocytosis and 23.81% showed increased liver enzyme levels. It is important to educate people on the risks associated with the systemic ingestion of Rhus.

Biological and toxicological evaluation of Rhus trilobata Nutt. (Anacardiaceae) used traditionally in mexico against cancer

BACKGROUND

Rhus trilobata Nutt. (Anacardiaceae) (RHTR) is a plant of Mexico that is traditionally used as an alternative treatment for several types of cancer. However, the phytochemical composition and potential toxicity of this plant have not been evaluated to support its therapeutic use. Therefore, this study aimed to evaluate the biological activity of RHTR against colorectal adenocarcinoma cells, determine its possible acute toxicity, and analyze its phytochemical composition.

METHODS

The traditional preparation was performed by decoction of stems in distilled water (aqueous extract, AE), and flavonoids were concentrated with C18-cartridges and ethyl acetate (flavonoid fraction, FF). The biological activity was evaluated by MTT viability curves and the TUNEL assay in colorectal adenocarcinoma (CACO-2), ovarian epithelium (CHO-K1) and lung/bronchus epithelium (BEAS-2B) cells. The toxicological effect was determined in female BALB/c mice after 24 h and 14 days of intraperitoneal administration of 200 mg/kg AE and FF, respectively. Later, the animals were sacrificed for histopathological observation of organs and sera obtained by retro-orbital bleeding for biochemical marker analysis. Finally, the phytochemical characterization of AE and FF was conducted by UPLC-MSE.

RESULTS

In the MTT assays, AE and FF at 5 and 18 μg/mL decreased the viability of CACO-2 cells compared with cells treated with vehicle or normal cells (p ≤ 0.05, ANOVA), with changes in cell morphology and the induction of apoptosis. Anatomical and histological analysis of organs did not reveal important pathological lesions at the time of assessment. Additionally, biochemical markers remained normal and showed no differences from those of the control group after 24 h and 14 days of treatment (p ≤ 0.05, ANOVA). Finally, UPLC-MSE analysis revealed 173 compounds in AE-RHTR, primarily flavonoids, fatty acids and phenolic acids. The most abundant compounds in AE and FF were quercetin and myricetin derivates (glycosides), methyl gallate, epigallocatechin-3-cinnamate, β-PGG, fisetin and margaric acid, which might be related to the anticancer properties of RHTR.

CONCLUSION

RHTR exhibits biological activity against cancer cells and does not present adverse toxicological effects during its in vivo administration, supporting its traditional use.

Contact Dermatitis to Carmine

: Carmine is a widely used "natural" food additive that has been reported to provoke both an immediate hypersensitivity and a delayed systemic response with cutaneous expression. Systemic contact dermatitis describes the hypersensitivity reaction following systemic re-exposure of the inciting allergen in previously sensitized individuals. In individuals with recalcitrant dermatitis and a positive carmine intolerance history and/or patch test, it is important to consider a trial topical and dietary elimination of carmine-associated products and foods.

A Novel Biflavonoid from Rhus leptodictya

An investigation of the leaves of Rhus leptodictya led to the isolation of the new biflavonoid: 5,5″,6″,7,8-pentahydroxy-2,2″-bis( p-hydroxyphenyl)-4 H,4″ H 3,7″-bichromene-4,4″-dione the structure of which was established by NMR spectroscopy and mass spectrometry.

Clinical Features of Systemic Contact Dermatitis Due to the Ingestion of Lacquer in the Province of Chungcheongnam-do

Background

Lacquer contains an allergen, which can cause severe contact dermatitis. Systemic dermatitis resulting from the ingestion of lacquer is quite common in Korea, until now.

Objective

The purpose of this study is to elucidate the clinical features and laboratory findings of systemic contact dermatitis (SCD), due to the ingestion of lacquer in Chungcheongnam-do.

Methods

We retrospectively reviewed the medical records of 33 patients with SCD, after ingestion of lacquer from Soonchunhyang University Hospital in Cheonan, over a 6-month period.

Results

In this study, 33.3% of patients ate lacquer, as a health food, and some (15.2%) by encouragement of friends or spouse. The most common way of ingestion was the lacquer-boiled chicken (48.5%), but many also ate lacquer tree sprouts (42.4%). The skin lesions developed as erythematous maculopapular eruptions, erythema multiforme, erythroderma, purpura, wheals and vesicles. On laboratory findings, 13 patients (52%) exhibited leukocytosis and 11 patients had elevated eosinophil counts.

Conclusion

The general public is becoming more aware of the toxic effects of lacquer ingestion, but still does not fully understand the dangers of lacquer tree sprouts, and this ignorance is frequently causing SCD in Chungcheongnam-do.

Systemic contact dermatitis

Systemic contact dermatitis is an inflammatory skin disease that may occur in persons with contact allergy when they are exposed to the hapten orally, transcutaneously, per rectum, intravesically, intravenously, or by inhalation. The most common causes of systemic contact dermatitis are drugs used both topically and systemically. Other causes are ubiquitously occurring haptens, such as the metals nickel, cobalt, gold, and chromate, and aromatic substances such as spices. Avoidance of the offending hapten is the most obvious treatment. For some haptens, such as nickel, diet treatment may be effective. Chelation therapy with disulfiram is another therapeutic option in nickel-allergic patients with systemic contact dermatitis. Hyposensitization therapy has been attempted with some success in systemic contact dermatitis caused by nickel and Parthenium hysterophorus.

Recent advances in research on lacquer allergy

Allergic contact dermatitis caused by contact with lacquer sap and lacquerware affects the welfare of lacquer workers and the lacquerware industry. Many studies of the mechanism of urushiol allergy, including animal models, have been carried out and have established several hypotheses. In order to provide a comprehensive understanding of lacquer allergy, we review recent advances in the research on lacquer allergy including the chemical properties of lacquer lipid components, allergic mechanism analyses, immunological explanations, allergy medications, and the prevention combined with the research results from our laboratory.

Efficacy and safety of standardized allergen-removed Rhus verniciflua Stokes extract in patients with advanced or metastatic pancreatic cancer: a Korean single-center experience

BACKGROUND

Pancreatic cancer has the worst prognosis because of poor response to conventional therapy. We investigated the clinical feasibility of the standardized allergen-removed Rhus verniciflua Stokes (aRVS) extract as a potential therapeutic agent for advanced or metastatic pancreatic cancer.

PATIENTS AND METHODS

From July 2006 to June 2010, patients with advanced or metastatic pancreatic adenocarcinoma were checked in our institution. After applying inclusion/exclusion criteria, 42 patients were eligible for the final analysis. Overall survival, clinical benefit and adverse events of these patients treated with aRVS in the aftercare period were determined.

RESULTS

In May 2011, 39 patients had died and the remaining 3 patients were alive with evidence of disease. The mean RVS administration period was 3.86 months (95% confidence interval 2.52-5.20). The median overall survival for the entire population was 7.87 months (95% confidence interval 5.14-10.59), and the 1-year survival rate was 26.2%, which is compatible with external controls. Using univariate and multivariate analyses, aRVS treatment including performance status and prognostic index significantly affected overall survival. A clinical benefit response was also shown by aRVS treatment which was not dependent on concurrent chemotherapy. Adverse reactions to aRVS treatment were mostly mild and self-limiting.

CONCLUSIONS

The standardized aRVS extract might be beneficial for patients with advanced or metastatic pancreatic cancer since it positively affected overall survival and clinical symptoms without significant adverse effects.

A systematic approach to systemic contact dermatitis and symmetric drug-related intertriginous and flexural exanthema (SDRIFE): a closer look at these conditions and an approach to intertriginous eruptions

Systemic contact dermatitis is a condition that occurs when an individual sensitized to a contact allergen is exposed to that same allergen or a cross-reacting molecule through a systemic route. Systemic exposure to allergens can include transcutaneous, transmucosal, oral, intravenous, intramuscular, and inhalational routes. Baboon syndrome is perhaps the most recognizable form of systemic contact dermatitis, presenting with diffuse, well demarcated erythema of the buttocks, upper inner thighs, and axillae. Other forms of systemic contact dermatitis include dermatitis at sites of previous exposure to the allergen such as at a previous site of dermatitis or at sites of previous positive patch tests, dyshidrotic hand eczema, flexural dermatitis, exanthematous rash, erythroderma, and vasculitis-like lesions. The most common causes of systemic contact dermatitis consist of three groups of allergens: (i) metals including mercury, nickel, and gold; (ii) medications including aminoglycoside antibacterials, corticosteroids, and aminophylline; and (iii) plants and herbal products including the Compositae and Anacardiaceae plant families and Balsam of Peru. Baboon syndrome caused by systemic medications without a known history of previous cutaneous sensitization in the patient has been termed drug-related baboon syndrome (DRBS) or symmetric drug-related intertriginous and flexural exanthema (SDRIFE). Criteria for SDRIFE include exposure to systemic drug at first or repeated dose, erythema of the gluteal/perianal area and/or V-shaped erythema of the inguinal area, involvement of at least one other intertriginous localization, symmetry of affected areas, and absence of systemic toxicity. The most common causes are aminopenicillins, β-lactam antibacterials, and certain chemotherapeutic agents, though the list of etiologic agents continues to grow. Baboon syndrome and SDRIFE should be strongly considered in a patient presenting with a symmetric intertriginous eruption involving multiple body folds. With the knowledge of the most frequent causes of these conditions, a detailed history and review of exposures will guide the clinician in the search for the most likely etiologic agent.

A case of recurred hepatocellular carcinoma refractory to doxorubicin after liver transplantation showing response to herbal medicine product, Rhus verniciflua Stokes extract

There is no established protocol proven to be beneficial for treatment of hepatocellular carcinoma recurrence after liver transplantation. Only a few reports have shown direct treatment by surgery or ablation to be independent predictors of survival for localized recurrence. Moreover, the necessity of immunosuppression to prevent allograft rejection makes many physicians hesitate to administer systemic chemotherapy. This case report documents a case in which the administration of an herbal product, an extract of the lacquer tree, Rhus verniciflua Stokes, was associated with a decrease in the size of lung metastases in a patient with recurrent hepatocellular carcinoma after liver transplantation refractory to doxorubicin. This patient experienced prolonged survival compared with average survival times and little toxicity.

Polymerized urushiol of the commercially available rhus product in Korea

BACKGROUND

Systemic contact dermatitis commonly occurs with the intake of rhus (boiled chicken with rhus) as a health food and a folk medicine to cure gastrointestinal diseases in Korea. Rhus companies insist they have the technology for rhus detoxification. However, the numbers of systemic allergic contact dermatitis patients, caused by rhus, have not decreased. The principle of present techniques for rhus detoxification is the induction of the polymerization of urushiol, but polymerized urushiol may still have antigenicity, although to a diminished degree. The Korean Food and Drug Administration (KFDA) has a regulation to control urushiol use as a food. However, the laboratory method that KFDA uses for detection of rhus can only detect the urushiol monomer.

OBJECTIVE

We conducted experiments to detect polymerized urushiol in rhus products, which were considered not to include urushiol by the KFDA.

METHODS

Rhus product approved by the KFDA was separated with chloroform. The chloroform fractionation was accomplished on a recycle HPLC system. Four peaks were achieved and evaporated to give an amorphous powder. Each powder was analyzed on a NMR system and mass spectrometer.

RESULTS

The material considered to be urushiol dimer, with a 638 molecular weight (MW), was detected in one of the four powders as per the HPLC peaks.

CONCLUSION

We concluded that commercially available rhus product is comprised of material considered to be urushiol dimer. Therefore, even if the antigenicity of the rhus products is low, this product may cause adverse effects and is not completely detoxified.

Plant poisoning

Each year over 100,000 exposures to toxic plants are reported to poison centers throughout the United States. Most of these exposures are of minimal toxicity largely because of the fact that they involve pediatric ingestions, which are of low quantity. The more serious poisonings usually involve adults who have either mistaken a plant as edible or have deliberately ingested the plant to derive perceived medicinal or toxic properties. The plants within this manuscript have been chosen because they have been documented to cause fatalities or account for emergency medicine visits. In this discussion, plants are grouped by their toxins rather than on the basis of their taxonomy.

Severe adverse cutaneous reaction to insulin due to cresol sensitivity

We present the case of an 80-year-old lady known to be sensitive to chlorocresol (4-chloro-3-methyl phenol) who developed severe erythrodermic exfoliative dermatitis with atypical features 2 weeks after commencing subcutaneous insulin. All medications except insulin were stopped, without major improvement. It was noted that the insulin contained m-cresol (m-methyl phenol) so a parabens-based insulin was substituted. There was a significant improvement in her clinical condition within 72 hr. Further patch and intradermal testing to the insulin and m-cresol was planned, but she developed a nosocomial infection and died. We hypothesize that the adverse cutaneous reaction was a systemic manifestation of cresol sensitivity, given the rapid clinical resolution on changing insulins and the previously demonstrated sensitivity to chlorocresol, particularly as cross-reactivity between different low molecular weight methyl phenols is documented. Local injection site reactions and systemic side-effects including nausea, diarrhoea and vomiting have previously been reported with cresol-containing insulins, although to our knowledge, this is the first reported case of a severe cutaneous reaction. It is important to be aware of m-cresol as a potential allergen, as it is contained in most commercially available insulins.