Case and Research Letter
Bullous Phytophotodermatitis Caused by an Esoteric Remedy
Fitofotodermatitis ampollosa producida por un remedio esotérico
S. Córdoba
, M. González, C. Martínez-Morán, J.M. Borbujo
Corresponding author
Servicio de Dermatología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
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Córdoba, M. González, C. Martínez-Morán, J.M. Borbujo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Córdoba" "email" => array:1 [ 0 => "susana.cordoba@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "González" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Martínez-Morán" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Borbujo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fitofotodermatitis ampollosa producida por un remedio esotérico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1738 "Ancho" => 2544 "Tamanyo" => 886584 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Erythema and edema on the dorsum of the right hand, with large tense blisters with a transparent content. B, Similar lesions on the dorsum of the left hand.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 33-year-old woman with a past history of hypothyroidism, anorexia nervosa, and anxiety-depression with episodes of self-harm. She was on treatment with levothyroxine, fluoxetine, clonazepam, and clomethiazole, and there had been no recent changes in her medication. She attended the emergency department for a 3-day history of large, painful blisters on the dorsum of both hands and fingers (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The blisters contained a serous fluid and the surrounding skin was erythematous and pruritic. The patient denied having applied any substance to the area or contact with plants, and at that moment she was off work because of her psychiatric illness and dedicated her time to walking and reading outside, even though it was winter. The lesions were reminiscent of large burns and, suspecting that they may have been self-inflicted, it was decided to admit the patient to observe the clinical course. During her admission, she was prescribed topical therapy with fusidic acid and betamethasone, and oral therapy with prednisone and amoxicillin–clavulanic acid, leading to an improvement in the lesions within a few days. On resolution of the acute bullous condition, we observed very clearly defined, diffuse pigmentation of a residual appearance on the skin distal to the wrists (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), but that did not affect the area covered by a ring; this suggested a possible diagnosis of phototoxicity. Additional tests performed, including extensive blood tests with autoimmune studies and 24-hour urinary porphyrin levels, determination of the minimal erythematous dose for UV-A and UV-B, and patch and photopatch testing with the standard series of the Spanish Contact Dermatitis and Skin Allergy Research Group and photoallergens of the Spanish Photobiology Group, were rigorously normal. Histology of the lesions showed a subepidermal blister with epidermal necrosis. Occasional apoptotic keratinocytes were observed in areas adjacent to the blister and a dermal infiltrate of lymphocytes, histiocytes, and eosinophils, with a number of extravasated red blood cells were observed in areas adjacent to the blister; these findings were compatible with a diagnosis of bullous phototoxic dermatitis. On further questioning, the patient finally remembered having applied a product prepared by a faith healer to combat an evil-eye curse 24 to 36<span class="elsevierStyleHsp" style=""></span>hours prior to onset of the lesions. This remedy consisted of an infusion of a plant called <span class="elsevierStyleItalic">rue</span>, which the patient had to apply all over her body except on her head. The site of the lesions coincided with the only area that had not been covered by her winter clothing after applying the substance.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Plants of the genus <span class="elsevierStyleItalic">Ruta</span> are small bushes originating from southern Europe that are cultured as ornamental plants in gardens and also for their medicinal properties and as a condiment. Among their many effects (abortifacient, antiparasitic, insect repellent, analgesic,…), they are widely known for their phototoxic capacity due to the furanocoumarins (5-methoxypsoralen and 8-methoxypsoralen) and alkaloids that they contains.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Numerous cases have been published of phytophotodermatitis due to the topical application of distinct species of <span class="elsevierStyleItalic">Ruta</span> for various therapeutic uses, such as pediculicide<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> or analgesic<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> lotions, or direct use of the plant as an insect repellent.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> In most cases, the clinical diagnosis is simple because of the site of the lesions in sun-exposed areas, the tendency to form vesicles or blisters, and the residual pigmentation, together with a history of contact with the plant or the application of substances that the plant contains.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Blister formation in the phytophotodermatoses can be intense, simulating extensive burns.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> In children, contact with phototoxic plants can be accidental, when playing in gardens, and is often not remembered.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The appearance of lesions similar to burns with no history of contact with plants can confound the diagnosis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Apart from its therapeutic applications, <span class="elsevierStyleItalic">Ruta</span> is used widely in some countries of the Iberian peninsula and Latin America to protect against “evil spirits”.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">7,8</span></a> The recommendation to apply products containing this plant all over the body, typically followed by exposure to the sun, perhaps even on the beach, gives rise to widespread lesions that only spare the areas covered by the bathing suit. Severe episodes of extensive phytophotodermatitis require a multidisciplinary approach with supportive measures in burns units.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We have presented a case of bullous phytophotodermatitis due to the use of <span class="elsevierStyleItalic">Ruta</span> in an unusual esoteric remedy against an evil-eye curse. A diagnosis of phytophotodermatitis must be suspected in patients with bullous lesions only affecting sun-exposed skin. On resolution, the lesions tend to produce well-defined residual pigmentation. It is also important to consider this diagnosis in children, in whom contact with the plant may be accidental and pass unnoticed.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Córdoba S, González M, Martínez-Morán C, Borbujo JM. Fitofotodermatitis ampollosa producida por un remedio esotérico. Actas Dermosifiliogr. 2017;108:79–81.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1738 "Ancho" => 2544 "Tamanyo" => 886584 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Erythema and edema on the dorsum of the right hand, with large tense blisters with a transparent content. B, Similar lesions on the dorsum of the left hand.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2026 "Ancho" => 2333 "Tamanyo" => 1003476 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diffuse pigmentation on the dorsum of the hands after resolution of the lesions. The clear limit at the distal borders of the wrists and the absence of involvement of the area under the ring on the fourth finger of the right hand are very striking.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Phytophotodermatitis due to common rue <span class="elsevierStyleItalic">(Ruta graveolens)</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.J. Gawkrodger" 1 => "J.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 12 | 25 |
| 2024 October | 87 | 66 | 153 |
| 2024 September | 83 | 44 | 127 |
| 2024 August | 101 | 82 | 183 |
| 2024 July | 89 | 37 | 126 |
| 2024 June | 111 | 46 | 157 |
| 2024 May | 89 | 50 | 139 |
| 2024 April | 86 | 31 | 117 |
| 2024 March | 81 | 37 | 118 |
| 2024 February | 74 | 44 | 118 |
| 2024 January | 65 | 33 | 98 |
| 2023 December | 71 | 21 | 92 |
| 2023 November | 69 | 29 | 98 |
| 2023 October | 85 | 24 | 109 |
| 2023 September | 81 | 28 | 109 |
| 2023 August | 70 | 21 | 91 |
| 2023 July | 89 | 27 | 116 |
| 2023 June | 71 | 26 | 97 |
| 2023 May | 76 | 32 | 108 |
| 2023 April | 56 | 32 | 88 |
| 2023 March | 71 | 37 | 108 |
| 2023 February | 55 | 31 | 86 |
| 2023 January | 46 | 36 | 82 |
| 2022 December | 65 | 34 | 99 |
| 2022 November | 39 | 24 | 63 |
| 2022 October | 47 | 16 | 63 |
| 2022 September | 43 | 35 | 78 |
| 2022 August | 52 | 23 | 75 |
| 2022 July | 40 | 36 | 76 |
| 2022 June | 35 | 16 | 51 |
| 2022 May | 75 | 33 | 108 |
| 2022 April | 65 | 32 | 97 |
| 2022 March | 74 | 48 | 122 |
| 2022 February | 32 | 19 | 51 |
| 2022 January | 96 | 36 | 132 |
| 2021 December | 71 | 56 | 127 |
| 2021 November | 49 | 52 | 101 |
| 2021 October | 65 | 48 | 113 |
| 2021 September | 97 | 50 | 147 |
| 2021 August | 117 | 33 | 150 |
| 2021 July | 85 | 30 | 115 |
| 2021 June | 47 | 37 | 84 |
| 2021 May | 39 | 44 | 83 |
| 2021 April | 97 | 64 | 161 |
| 2021 March | 58 | 38 | 96 |
| 2021 February | 52 | 38 | 90 |
| 2021 January | 41 | 16 | 57 |
| 2020 December | 32 | 24 | 56 |
| 2020 November | 32 | 25 | 57 |
| 2020 October | 23 | 13 | 36 |
| 2020 September | 29 | 19 | 48 |
| 2020 August | 36 | 42 | 78 |
| 2020 July | 25 | 18 | 43 |
| 2020 June | 30 | 38 | 68 |
| 2020 May | 13 | 19 | 32 |
| 2020 April | 22 | 17 | 39 |
| 2020 March | 18 | 14 | 32 |
| 2020 February | 5 | 0 | 5 |
| 2020 January | 2 | 0 | 2 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 3 | 0 | 3 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 7 | 1 | 8 |
| 2019 April | 2 | 5 | 7 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 1 | 0 | 1 |
| 2018 December | 8 | 0 | 8 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 5 | 0 | 5 |
| 2018 February | 39 | 2 | 41 |
| 2018 January | 24 | 7 | 31 |
| 2017 December | 63 | 13 | 76 |
| 2017 November | 25 | 3 | 28 |
| 2017 October | 18 | 6 | 24 |
| 2017 September | 19 | 5 | 24 |
| 2017 August | 21 | 9 | 30 |
| 2017 July | 15 | 7 | 22 |
| 2017 June | 33 | 10 | 43 |
| 2017 May | 27 | 12 | 39 |
| 2017 April | 32 | 16 | 48 |
| 2017 March | 34 | 19 | 53 |
| 2017 February | 54 | 34 | 88 |
| 2017 January | 48 | 33 | 81 |
| 2016 December | 4 | 14 | 18 |
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