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Phytophotodermatitis due to puncture from lime tree thorn.

To the Editor: Phytophotodermatitis is a cutaneous phototoxic phototoxic /pho·to·tox·ic/ (fo´to-tok?sik) having a toxic effect triggered by exposure to light.

Rendering the skin susceptible to damage by light.
 inflammatory eruption due to exposure to light-sensitizing botanical substances and longwave ultraviolet radiation that usually begins approximately 24 hours after exposure and peaks at 48 to 72 hours. (1) The primary skin lesions of phytophotodermatitis may range from delayed erythema (24-48 h) to a frankly nodular eruption. The photosensitizing photosensitizing

causing photosensitivity.

photosensitizing plants
some plants carry primary photodynamic agents, e.g. Hypericum perforatum.
 compounds in the plants are furocoumarins. The phototoxic reaction is entirely independent of the immune system; thus, prior sensitization sensitization /sen·si·ti·za·tion/ (sen?si-ti-za´shun)
1. administration of an antigen to induce a primary immune response.

2. exposure to allergen that results in the development of hypersensitivity.
 or an intact immune system is not required. The clinical history is essential in establishing the diagnosis of phytophotodermatitis.

While picking limes from a Tahitian lime tree located in the Paradise Park area of Kea'au, Hawaii, a 69-year-old Caucasian man developed phytophotodermatitis after puncture of the skin in the right scapular scap·u·lar or scap·u·lar·y
Of or relating to the shoulder or scapula.

adj pertaining to the region of the scapulae.


pertaining to the scapula.
 area by a thorn. The patient's back was exposed to the sun the following day. Lesions first developed slightly more than 24 hours after the initial injury and peaked at 36 hours. Three large, red, raised lesions were observed, and two had central vesicles. Following symptomatic treatment with 2% diphenhydramine diphenhydramine /di·phen·hy·dra·mine/ (di?fen-hi´drah-men) a potent antihistamine, used as the hydrochloride salt in the treatment of allergic symptoms and for its anticholinergic, antitussive, antiemetic, antivertigo, and antidyskinetic  spray and triple antibiotic ointment (bacitracin bacitracin (băs'ĭtrā`sĭn), antibiotic produced by a strain of the bacterial species Bacillus subtilis. It is widely used for topical therapy such as for skin and eye infections; it is effective against gram-positive bacteria, , neomycin neomycin (nē'ōmī`sĭn), broad spectrum antibiotic effective against both gram positive and gram negative bacteria (see Gram's stain). , and polymyxin B), beginning resolution of the lesions was noted by the same evening, and complete resolution occurred over a week's time. There was no pruritus pruritus /pru·ri·tus/ (proo-ri´tus) itching.prurit´ic

pruritus a´ni  intense chronic itching in the anal region.

pruritus hiema´lis  xerotic eczema.
 or residual cutaneous hyperpigmentation. The past history was negative for asthma, hay fever, or allergic reactions to medications.

The present case had some unusual features. The patient had an asymptomatic lime thorn scratch over the right forearm, whereas the central scapular lesion developed after a puncture wound from the lime thorn, and the satellite scapular lesions apparently resulted from spread due to scratching by the patient. This suggests that more of the irritating substance was introduced through the puncture.

The onset of dermatitis is variable, however, and may begin within a few hours to days after exposure. (2) Recent evidence supports it being a type of irritant contact dermatitis irritant contact dermatitis Occupational dermatology A form of CD that usually affects the hands and arms, caused by acids, alkalis; the intensity of skin response reflects intrinsic nature of the chemical, its concentration, and duration of contact Clinical . (3,4) The sap of the tree and scratches by the thorns may cause rashes in sensitive individuals. A variety of reactions have been noted as a result of exposure to citrus peel. (5) Many plants, including limes, contain furocoumarins (psoralens) that cause phytophotodermatitis by forming phototoxic compounds on exposure to ultraviolet A radiation. (3,4) After resolution of the phototoxic reaction, postinflammatory hyperpigmentation may occur.

Phototoxic reactions to exposure to lime can be polymorphous in nature. Due to the bizarre configurations of lesions induced by phytophotodermatitis, it can be confused with many other diseases, especially in children. (2) A detailed clinical history is crucial in establishing the correct diagnosis of phytophotodermatitis. The treatment of acute phytophotodermatitis is primarily symptomatic with the lesions responding well to the application of topical corticosteroids and cold compresses. (2) Mild cases may not require treatment.

Lawrence M. Roth, MD

Department of Pathology

Indiana University School of Medicine The Indiana University School of Medicine is the medical school of Indiana University, part of the Indiana University Purdue University at Indianapolis (IUPUI) campus located in Indianapolis, Indiana. Established in 1903, the school had an initial class of 25 students.  

Indianapolis, Indiana

Elizabeth H. Levin, MD

Department of Psychiatry

UMDNJ--Robert Wood Johnson Medical School

Camden, New Jersey The City of Camden is the county seat of Camden County, New Jersey in the United States. It is located just across the Delaware River from Philadelphia, Pennsylvania. As of the United States 2000 Census, the city had a total population of 79,904.  

Arthur H. Schwartz, MD

Retired Professor of Psychiatry

UMDNJ--Robert Wood Johnson Medical School

Piscataway, New Jersey

David J. Roth, BA

Jerusalem, Israel


1. Baugh WP, Barnette D Jr. Phytophotodermatitis. emedicine [August 24, 2005; Accessed March 1, 2006].

2. Goskowicz MO, Friedlander SF, Eichenfield LF. Endemic 'lime' disease: phytophotodermatitis in San Diego County. Pediatrics 1994;93:828-830.

3. Nigg HN, Nordby HE, Beier RC, et al. Phototoxic coumarins in limes. Food Chem Toxicol 1993;31:331-335.

4. Wagner AM, Wu JJ, Hansen RC, et al. Bullous bullous /bul·lous/ (bul´us) pertaining to or characterized by bullae.

Relating to or characterized by bullae.
 phytophotodermatitis associated with high natural concentrations of furanocoumarins in limes. Am J Contact Dermat 2002;13:10-14.

5. Solis RR, Dotson DA, Trizna Z. Phytophotodermatitis: a sometimes difficult diagnosis. Arch Fam Med 2000;9:1195-1196.
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Title Annotation:Letters to the Editor
Author:Roth, David J.
Publication:Southern Medical Journal
Date:May 1, 2007
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