Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
 
Users online: 2896  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page


 
Table of Contents 
CASE REPORT
Year : 2011  |  Volume : 56  |  Issue : 3  |  Page : 329-331
Phytophotodermatitis due to chinese herbal medicine decoction


1 Department of Dermatology, The First Affiliated Hospital of Bengbu Medical College, Anhui, China
2 Department of Dermatology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China

Date of Web Publication30-Jun-2011

Correspondence Address:
Wenyuan Zhu
Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210 029
China
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.82498

Rights and Permissions

   Abstract 

A 24-year-old female presented to the clinic complaining of bizarre patterns and linear streaks of hyperpigmentation on her legs and bizarre alutaceous patches on the neck and upper breast of her son for 7 days. Physical examination showed sharply demarcated hyperpigmented streaks on the extensor aspects of legs and bizarre brown maculae and patches on the right neck and upper chest of her son. Considering the history of Chinese herbal medicine decoction had been splashed onto these sites, phytophotodermatitis was definitely diagnosed.


Keywords: Chinese herbal medicine, decoction, phytophotodermatitis


How to cite this article:
Zhang R, Zhu W. Phytophotodermatitis due to chinese herbal medicine decoction. Indian J Dermatol 2011;56:329-31

How to cite this URL:
Zhang R, Zhu W. Phytophotodermatitis due to chinese herbal medicine decoction. Indian J Dermatol [serial online] 2011 [cited 2020 Jul 13];56:329-31. Available from: http://www.e-ijd.org/text.asp?2011/56/3/329/82498



   Introduction Top


Phytophotodermatitis connotes phototoxic reactions consisting of erythema (with or without blistering) and delayed hyperpigmentation. [1] It is entirely independent of the immune system; that is, phytophotodermatitis can occurs in any individual and does not require prior sensitization. The ingredients needed to produce phytophotodermatitis include temporal exposure to both a photosensitizing substance (such as furocoumarins) and the appropriate wavelength of ultraviolet radiation (UVR). [1] Herein, we first report two cases of phytophotodermatitis after contact with Chinese herbal medicine (CHM) decoction.


   Case Reports Top


Case 1

On June 28 th 2009, a Chinese 24-year-old female presented to the clinic with a 7-day history of linear hyperpigmentation on her legs. Physical examination showed sharply demarcated hyperpigmented lines and curves on the extensor aspects of thighs and legs [Figure 1], bizarre fuscescent patches on the dorsal aspects of laps [Figure 2]. The patient complained of mild burning erythema on these sizes before 4 days, without any treatment, the preceding inflammatory reaction disappeared and left behind these rebarbative brown lines. We explored the history of exposure to any plants. She remembered that, before the onset of the rash, she had prepared the decoction of CHM (including atractylodes macrocephala, Cicada Slough, Pheretima asiatica, liquorice root, Astragalus mongholicus, Chinese Angelica, Sinensis, Pricklyash peel, Common Selfheal Fruit-Spike) for her son (Case 2). During the process, inadvertent splash of CHM decoction onto the skin happened to her and her son. At that time, she was in a skirt; the decoction was sprayed onto the dorsal aspects of laps and trickled down the legs to the ankles. Subsequently, she had extensive sun exposure throughout the day. One day thereafter, she developed mild erythema with slight and transient burning sensation on the sites of contact with the CHM decoction. Ultimately, a final diagnosis of phytophotodermatitis was established. The patient was prescribed with topical complex arbutin cream twice daily and vitamin C by mouth. The hyperpigmentation over the affected areas was slightly lightened 2 months after the initial clinical presentation.
Figure 1: Sharply demarcated hyperpigmented lines and curves on the extensor aspects of thighs and legs

Click here to view
Figure 2: Bizarre fuscescent patches on the dorsal aspects of laps

Click here to view


Case 2

An 11-month-old boy, the son of case 1, was referred to for evaluation of alutaceous maculae and patches on his right neck and upper chest [Figure 3] for 7 days. The boy suffered from fever cough and was prescribed with the CHM decoction (above mentioned) peros. Frequently, the boy struggled and refused to drink this decoction because of its bitter in taste. The physic liquor was sporadically sprinkle on his perioral areas and run down onto neck and upper chest, even splashed onto his mother's legs in one time. The child was exposed to sunlight. During the subsequent 24 h, a burning erythema developed on these sites, disappeared within 3−4 days, and remained brown patches.
Figure 3: Alutaceous maculae and patches on right neck and upper chest of the boy

Click here to view


Physical examination showed bizarre hyperpigmented maculae and patches with blurry borders on his right neck and upper chest. The skin covered by his suit was spared. Without any treatment, the light tan maculae and patches resolved during the 2-month follow-up.


   Discussion Top


Phytophotodermatitis is a common cutaneous phototoxic reaction. Contact with plant-derived phototoxic substances (frequently found in umbilliferae, moracea, rutaceae, and leguminous) followed by sunlight exposure produces the clinical lesions. Furocoumarins, which are frequently found in limes, lemons, oranges, celery, fig, parsnip, parsley, carrots, dill, and perfumes, are photosensitizing chemical components and consist of psoralens, 5-methoxypsoralens, 8-methoxypsoralens, angelicin, bergaptol, and xanthotal. [2],[3],[4] The wavelengths of ultraviolet light that most efficiently produce phytophotodermatitis lie within the UV-A range and have peak activity at 335 nm.

Two distinct photochemical reactions have been described in phytophotodermatitis. 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. This results in activation of arachidonic acid metabolic pathways and in cell death (sunburn cells and apoptotic keratinocytes). [5] Clinically, erythema, blistering, epidermal necrosis, and eventual epidermal desquamation occur.

A postinflammatory pigment alteration may follow the acute phase of this phototoxic reaction. This alteration occurs primarily by two mechanisms. First, melanin, which is normally found in the epidermis, "falls" into the dermis and is ingested by melanophages. Second, 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 seen as the end stage of the phototoxic reaction.

Phytophotodermatitis most commonly occurs in the spring and the summer when furocoumarins are at their highest concentration in plants and when UV exposure is greatest for patients. It is frequently found in people who spend a lot of time participating in outdoor activities, [6] beach-goers, and children playing outdoors. Therefore, phytophotodermatitis is most commonly found on skin sites exposed to plants and sunlight, such as arm and leg, but it may occur anywhere. Its acute phase manifests as erythema, and end stage as postinflammatory hyperpigmentation. Lesions may or appear as hyperpigmented patches without a preceding erythematous phase, as happened in Case 1. Bizarre inflammatory patterns and linear streaks of hyperpigmentation are key clues to diagnosing phytophotodermatitis. These patterns often result from brushing against a plant's stems or leaves while outdoors or from the liquid spread of lime juice over the hand or down the forearm.

Jorge et al.[7] reproduce phytophotodermatitis in animal models by spraying peel juice of Tahiti lemon onto the skin of epilated albino rats and observe its serial pathological changes. After 24 h spongiosis, vacuolization and keratinocyte necrosis are observed, clinically there are no changes. After 48 h, erythema appears with intra- and subepidermal blistering. Almeida et al.[8] examined the epidermis in induced phytophotodermatitis using transmission electron microscopy in order to detect histological changes even before lesions are visible by light microscopy, they found vacuolization in keratinocytes immediately after induction. After 1 h, desmosomal changes were also observed in addition to vacuolization. Keratin filaments were not attached to the desmosomal plaque. Free desmosomes and membrane ruptures were also seen. At 2 h after induction, similar changes were found, and granular degeneration of keratin was also observed.

Phytophotodermatitis is a clinical diagnosis. The sunburn like 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.

There is no specific treatment for phytophotodermatitis. [9] Most commonly, it is a localized cutaneous phenomenon resulting initially in a burning sensation. In severe cases, analgesics, antihistamines for itching, and wet compresses may be used. Blistered areas should be kept clean to prevent secondary infection. Eventually, the affected sites may desquamate and develop permanent hyperpigmentation or hypopigmentation. However, scarring is rare.

Comparing with previous description about phytophotodermatitis, our report has the following characteristics. First, our patients' lesions were caused by inadvertent splash of CHM decoction onto the skin, did not result from exposure to fresh fluid of plants. The boiled CHM included eight kinds of plant in which Chinese angelica and Pricklyash peel containing furocoumarins that can induce phytophotodermatitis. Second, the lesions in case 1 mainly presented bizarre hyperpigmented lines and curves depending on how the decoction drip over the skin surface without obviously acute inflammatory reaction such as erythema and blister.

 
   References Top

1.Solis RR, Dotson DA, Trizna T. Phytophotodermatitis: A sometimes difficult diagnosis. Arch Fam Med 2000;9:1195-6.  Back to cited text no. 1
    
2.Lenković M, Cabrijan L, Gruber F, Saftić M, Stanić Zgombić Z, Stasić A, et al . Phytophotodermatitis in Rijeka region, Croatia. Coll Antropol 2008;32:203-5.  Back to cited text no. 2
    
3.Morais P, Mota A, Cunha AP, Peralta L, Azevedo F. Phytophotodermatitis due to homemade ointment for Pediculosis capitis. Contact Dermatitis 2008;59:373-4.  Back to cited text no. 3
    
4.Polat M, Oztas P, Dikilitas MC, Alli N. Phytophotodermatitis due to Ficus carica. Dermatol Online J 2008;14:9.  Back to cited text no. 4
    
5.Tunget CL, Turchen SG, Manoguerra AS, Clark RF, Pudoff DE. Sunlight and the plant: a toxic combination: severe phytophotodermatitis from Cneoridium dumosum. Cutis 1994;54:400-2.  Back to cited text no. 5
    
6.Wild G. Phytophotodermatitis after gardening. J R Army Med Corps 2008;154:245-6.  Back to cited text no. 6
    
7.Jorge VM, de Almeida HL Jr, Amado M. Serial light microscopy of experimental phytophotodermatitis in animal model. J Cutan Pathol 2009;36:338-41.  Back to cited text no. 7
    
8.Almeida HL Jr, Sotto MN, Castro LA, Rocha NM. Transmission electron microscopy of the preclinical phase of experimental phytophotodermatitis. Clinics (Sao Paulo) 2008;63:371-4.  Back to cited text no. 8
    
9.Bowers AG. Phytophotodermatitis. Am J Contact Dermat 1999;10:89-93.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]

This article has been cited by
1 The ultrastructural effects of long-term use of henna on the albino rat skin
Al-Shobaili, H.A., El-Bassouny, D.R.
Source of the Document Histology and Histopathology. 2014;
[Pubmed]



 

Top
Print this article  Email this article
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (1,023 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    Case Reports
    Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed4341    
    Printed97    
    Emailed0    
    PDF Downloaded47    
    Comments [Add]    
    Cited by others 1    

Recommend this journal