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
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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 15 | 12 | 27 |
| 2024 Octubre | 87 | 66 | 153 |
| 2024 Septiembre | 83 | 44 | 127 |
| 2024 Agosto | 101 | 82 | 183 |
| 2024 Julio | 89 | 37 | 126 |
| 2024 Junio | 111 | 46 | 157 |
| 2024 Mayo | 89 | 50 | 139 |
| 2024 Abril | 86 | 31 | 117 |
| 2024 Marzo | 81 | 37 | 118 |
| 2024 Febrero | 74 | 44 | 118 |
| 2024 Enero | 65 | 33 | 98 |
| 2023 Diciembre | 71 | 21 | 92 |
| 2023 Noviembre | 69 | 29 | 98 |
| 2023 Octubre | 85 | 24 | 109 |
| 2023 Septiembre | 81 | 28 | 109 |
| 2023 Agosto | 70 | 21 | 91 |
| 2023 Julio | 89 | 27 | 116 |
| 2023 Junio | 71 | 26 | 97 |
| 2023 Mayo | 76 | 32 | 108 |
| 2023 Abril | 56 | 32 | 88 |
| 2023 Marzo | 71 | 37 | 108 |
| 2023 Febrero | 55 | 31 | 86 |
| 2023 Enero | 46 | 36 | 82 |
| 2022 Diciembre | 65 | 34 | 99 |
| 2022 Noviembre | 39 | 24 | 63 |
| 2022 Octubre | 47 | 16 | 63 |
| 2022 Septiembre | 43 | 35 | 78 |
| 2022 Agosto | 52 | 23 | 75 |
| 2022 Julio | 40 | 36 | 76 |
| 2022 Junio | 35 | 16 | 51 |
| 2022 Mayo | 75 | 33 | 108 |
| 2022 Abril | 65 | 32 | 97 |
| 2022 Marzo | 74 | 48 | 122 |
| 2022 Febrero | 32 | 19 | 51 |
| 2022 Enero | 96 | 36 | 132 |
| 2021 Diciembre | 71 | 56 | 127 |
| 2021 Noviembre | 49 | 52 | 101 |
| 2021 Octubre | 65 | 48 | 113 |
| 2021 Septiembre | 97 | 50 | 147 |
| 2021 Agosto | 117 | 33 | 150 |
| 2021 Julio | 85 | 30 | 115 |
| 2021 Junio | 47 | 37 | 84 |
| 2021 Mayo | 39 | 44 | 83 |
| 2021 Abril | 97 | 64 | 161 |
| 2021 Marzo | 58 | 38 | 96 |
| 2021 Febrero | 52 | 38 | 90 |
| 2021 Enero | 41 | 16 | 57 |
| 2020 Diciembre | 32 | 24 | 56 |
| 2020 Noviembre | 32 | 25 | 57 |
| 2020 Octubre | 23 | 13 | 36 |
| 2020 Septiembre | 29 | 19 | 48 |
| 2020 Agosto | 36 | 42 | 78 |
| 2020 Julio | 25 | 18 | 43 |
| 2020 Junio | 30 | 38 | 68 |
| 2020 Mayo | 13 | 19 | 32 |
| 2020 Abril | 22 | 17 | 39 |
| 2020 Marzo | 18 | 14 | 32 |
| 2020 Febrero | 5 | 0 | 5 |
| 2020 Enero | 2 | 0 | 2 |
| 2019 Diciembre | 8 | 0 | 8 |
| 2019 Noviembre | 3 | 0 | 3 |
| 2019 Septiembre | 8 | 0 | 8 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 7 | 1 | 8 |
| 2019 Abril | 2 | 5 | 7 |
| 2019 Marzo | 2 | 0 | 2 |
| 2019 Febrero | 1 | 0 | 1 |
| 2018 Diciembre | 8 | 0 | 8 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 5 | 0 | 5 |
| 2018 Febrero | 39 | 2 | 41 |
| 2018 Enero | 24 | 7 | 31 |
| 2017 Diciembre | 63 | 13 | 76 |
| 2017 Noviembre | 25 | 3 | 28 |
| 2017 Octubre | 18 | 6 | 24 |
| 2017 Septiembre | 19 | 5 | 24 |
| 2017 Agosto | 21 | 9 | 30 |
| 2017 Julio | 15 | 7 | 22 |
| 2017 Junio | 33 | 10 | 43 |
| 2017 Mayo | 27 | 12 | 39 |
| 2017 Abril | 32 | 16 | 48 |
| 2017 Marzo | 34 | 19 | 53 |
| 2017 Febrero | 54 | 34 | 88 |
| 2017 Enero | 48 | 33 | 81 |
| 2016 Diciembre | 4 | 14 | 18 |
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