Asymptomatic Hyperpigmentation without Preceding Inflammation as a Clinical Feature of Citrus Fruits-Induced Phytophotodermatitis

Phytophotodermatitis is a condition that occurs by contact with plants containing phototoxic agents such as furocoumarins and psoralens with subsequent ultraviolet exposure. Phytophotodermatitis typically presents as sharply defined erythematous patches with occasional blistering, sometimes accompanied with pain or itching sensation. In some cases, however, sudden appearance of asymptomatic hyperpigmentation can be the only clinical finding of phytophotodermatitis. Here, we present two patients with sudden development of asymptomatic pigmentation on their hand without preceding inflammation by the contact with citrus fruits containing photosensitizers and subsequent exposure to strong sunlight. As like these patients, phytophotodermatitis can present with only pigmentation without noticeable inflammation especially in dark skinned people. In such cases, physician can sometimes have difficulty in diagnosis of phytophotodermatitis. Therefore, it is important to consider the possibility of phytophotodermatitis through careful history taking, especially in patients who have abruptly developed well-defined hyperpigmentation on sun-exposed areas, to avoid unnecessary test and treatment.

Plant Associated Irritant & Allergic Contact Dermatitis (Phytodermatitis)

With more than 350,000 plant species recognized and new species continually being identified, it is not surprising that humans contact plants or plant-containing products daily. The nearly endless list of potential exposures leaves us with a challenging task when attempting to categorize and study potential plant-related irritants and allergens. This article focused on laying a sound framework for understanding some of the more pertinent potential irritants and allergens.

Babchi oil-induced phytophotodermatitis mimicking burn injury

Babchi (Psorylea corylifolia) is occasionally used by patients as a herbal treatment in conditions such as psoriasis and vitiligo, due to its anti-inflammatory, anti-oxidant and immune-modulatory properties (Shrestha et al., 2018; Chopra et al., 2013). Due to its psoralen containing furocoumarins, it has the potential to induce photosensitive reactions. We present the first reported case of Babchi-induced phytophotodermatitis in the UK, presenting as sunburn.

Common Dermatologic Conditions in Returning Travelers

Purpose of Review

Travel medicine practitioners often are confronted with returning travelers with dermatologic disorders that could be of infectious causes or inflammatory or allergic. Some dermatologic processes are the result of exposure to insects or acquired due to environmental exposures. There is a broad range of dermatosis of infectious and non-infectious etiologies that clinicians need to consider in the differential diagnosis of dermatosis in travelers.

Recent Findings

With increasing international travel to tropical destinations, many individuals may be exposed to rickettsia (i.e., African tick bite fever, scrub typhus, or Mediterranean spotted fever), parasitic infections (i.e., cutaneous larva migrans, cutaneous leishmaniasis, African trypanosomiasis, or American trypanosomiasis), viral infections (i.e., measles or Zika virus infection), bacterial (i.e., Buruli ulcer) or ectoparasites (scabies or tungiasis), and myiasis. Cutaneous lesions provide clinical clues to the diagnosis of specific exposures during travel among returned travelers.

Summary

Dermatologic disorders represent the third most common health problem in returned travelers, after gastrointestinal and respiratory illness. Many of these conditions may pose a risk of severe complications if there is any delay in diagnosis. Therefore, clinicians caring for travelers need to become familiar with the most frequent infectious and non-infectious skin disorders in travelers.

[Irritant contact dermatitis caused by direct contact with oleander (Nerium oleander)]

BACKGROUND

Although the oleander plant is practically ubiquitous throughout the Mediterranean area, very few publications refer to its cutaneous toxicity.

PATIENTS AND METHODS

Herein, we report two cases of irritant contact dermatitis caused by oleander. The patients in question were twins who had oleander leaves applied directly to their face for 20minutes. The initial lesions consisted of periorbital erythema, followed by the emergence of papules and macules. Vesicles and crusts appeared over the ensuing 24hours. Treatment included withdrawal of the toxic agent, prescription of oral antihistamines, and the topical application of dermocorticoids to the lesions for two weeks. The outcome on the 9th day was slightly hypochromic and atrophic. Complete restitutio ad integrum of the skin was observed after 30 days.

DISCUSSION

In our patients, a joint effect of ultraviolet radiation (phytophotodermatitis) and chlorine from the swimming pool cannot be ruled out. Although the substances present in oleanders (irritant saponins and glycosides) can cause chemical irritant dermatitis, immunological reactions cannot be excluded. The lack of signs of systemic toxicity observed is the result of the factors governing transdermal diffusion of the toxic glycosides found in oleander.

CONCLUSION

These two cases provide a timely reminder, both for the general public and for healthcare professionals, of the potential biohazards of oleander, not only because of its systemic toxicity but also because of the risks associated with cutaneous exposure.

Margarita Burn: Recognition and Treatment of Phytophotodermatitis

Phytophotodermatitis is a cutaneous reaction caused by direct contact with phototoxic agents and subsequent sunlight exposure. Furocoumarins and psoralens are 2 phototoxic agents that can cause this reaction, and these organic chemical compounds are found in many plant species consumed by humans. Following contact exposure to such foods and ultraviolet radiation exposure via direct sunlight, phytophotodermatitis can occur. Due to the etiology of these rashes relating closely to the outdoor consumption of margaritas, the rash may be known by patients as "margarita burn." There is a classically described sequence of rash progression: erythematous macules or patches, which later become vesicles and seem similar to second-degree burns, followed by an asymptomatic hyperpigmentation. This case presents a 26-year-old female diagnosed with phytophotodermatitis following use of citrus fruits for margaritas while outdoors in direct sunlight. The diagnosis of phytophotodermatitis is often made clinically but can be complicated due to its similarity in appearance to many other common cutaneous reactions. In this patient, the differential diagnosis included solar erythema, contact dermatitis (type IV hypersensitivity reaction), polymorphic light eruption, or drug-related photosensitivity. Careful history taking is essential in not only narrowing down the differential diagnosis but also in avoiding unnecessary tests or ineffective treatments.

Phytophotodermatitis due to a Citrus-Based Hand Sanitizer: A Case Report

Phytophotodermatitis, a cutaneous reaction caused by direct contact with photosensitive substances in plants and subsequent exposure to ultraviolet light, is commonly caused by psoralens in plants, including citrus fruits. We describe a case of phytophotodermatitis caused by a hand sanitizer containing a blood orange (Citrus sinensis) extract. To our knowledge, this is the first reported case of phytophotodermatitis caused by a hand sanitizer. A 41-year-old woman presented with a 2-week history of pruritic cutaneous eruptions on her right thigh. Approximately 24 hours prior to the onset of her symptoms, she applied a new citrus-based hand sanitizer. Immediately after applying the hand sanitizer, her right thigh was exposed to sunlight for approximately 5 hours. Extracts from oranges are used in many cosmetics, including perfumes and fragrances. With the increased use of hand sanitizers during the coronavirus disease 2019 pandemic, physicians should note that phytophotodermatitis due to scented hand sanitizers may occur more frequently.

Phytophotodermatitis as a clinical problem and as a therapeutic option: Case report and review of the literature

BACKGROUND

Phytophotodermatitis is a contact photodermatitis to furocoumarins, which act as sensitizing psoralens, from certain plants, especially citrus and fig trees. This photosensitizing effect has traditionally been used for the treatment of cutaneous viral warts, a reflection of traditional medicine. However, there are hardly any studies that support this fact. Otherwise, on certain occasions, especially in extensive exposures, they can cause a generalized severe condition that can even put the patient's life at risk.

CASE PRESENTATION

We report the case of a 28-year-old man with severe phytophotodermatitis after generalized photoexposure with the manipulation of a fig tree, which required hospital management in a burn unit.

RESULTS

A traditional method for the treatment of warts in some rural areas, especially in Iran, comprises the use of fig tree (ficus carica) latex as a local treatment; however, there is no scientific evaluation of its efficacy. It bases its effectiveness on physical destruction due to the sensitizing effect of furocoumarins. Though, in generalized exposures of this tree, as the case of our patient, can cause fatal symptoms. The essential therapeutic pillar is the avoidance of exposure to this tree and of sun exposure. Symptomatically, topical corticosteroids and systemic antihistamines are used. In severe cases, admission to a burn unit may be necessary.

CONCLUSION

In conclusion, we highlight the importance the importance of early detection of phytophotodermatitis, an entity that can be caused by the daily handling of trees, including fig trees, a traditional remedy for viral warts and which, without adequate supervision in its application, can cause severe generalized symptoms.