History: The patient's brother was seen for an unrelated problem and asked if I would look at a picture on his cell phone. His brother, a 30-year-old man, recently returned from the Bahamas where he developed a pruritic inflammatory skin disorder. The cell phone image was hazy, but interesting and I asked if his brother could come in that day. He did, and anamnesis revealed that he had been drinking Corona beer with lime and remembers rubbing his abdomen at that time. Twenty-four to 36 hours later, he developed blisters and erythema at the site where he rubbed his skin. He thought it was from the limes, but his friends told him this was fanciful.
O/E: The examination showed streaky erythema on the right hip. The lesions are along the lines of where he rubbed with his fingers.
Clinical Photo(s)
Brother will cell-phone
Patient demonstrating how he remembers rubbing his abdomen.
Lab: N/A
Histopathology: N/A
Diagnosis or DDx: Phytophotocontact Dermatitis due to Lime (Rutaceae)
Questions: N/A
Reason(s) Presented: Presented for interest. It would be possible for a patient to send an image to his dermatologist from the Bahamas on his cell phone and a tentative diagnosis arrived at. Knowing that limes contain furocoumarin (a potent photosensitizer) could have led to a more timely diagnosis. If treatment was initiated very early, some of the post-inflammatory hyperpigmentation might have been avoided. At that time, wet compresses and topical corticosteroids could have shortened the course of the inflammation.
Discussion: See reference. Limes, lemons and a number of other plants contain furocoumarin. To develop phytophotocontact dermatitis, an individual needs to have contact with the agent and then get sun-exposure before washing the skin. Then, 24 - 36 hours later an exaggerated sunburn develops which heals with post-inflammatory hyperpigmentaton. The pigment change is more pronounced in darker individuals and can last many months. It usually fades over time.
Reference: Hyperpigmented Macules and Streaks
3 comments:
THIS IS FROM DR. LILIANA RIVIS:
This is a great case. I do not think I would have known what it is.
I have found a link with some common plants that can give this rash.
I think many people are eating parsley and do not get this rash. Maybe is something more to it.
http://dermnetnz.org/reactions/photocontact-dermatitis.html
This is a good example of mobile teledermatology. One can snap a picture with your handphone and transmit that image for a clinical opinion. In fact I have patients who have taken images of their own lesions eg urticaria,etc and later brought the handphone with built-in camera to the clinic to show us what it looked like initially.
I agree this is phytophotocontact dermatitis caused by contact with lime. This is somewhat similar to berloque photocontact dermtitis.
FROM KATHY WISTAR
I just wanted to mention that I have actually seen this rash in a couple of patients, and have had very personal experience with it after pulling up several wild parsnip plants in my yard. I developed a painless blister on my leg, which disappeared after a week or so, leaving a hyperpigmented area that stayed with me for about a year.
My daughter got a much more serious rash, but it resolved after about 3 months. No pain, minimal pruritis. If you google wild parsnip you can see pictures of the rash and the plant, as well as lists of other plants that cause the rash.
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