Plant dermatitis: asian perspective

Occupational and recreational plant exposure on the skin is fairly common. Plant products and extracts are commonly used and found extensively in the environment. Adverse reactions to plants and their products are also fairly common. However, making the diagnosis of contact dermatitis from plants and plant extracts is not always simple and straightforward. Phytodermatitis refers to inflammation of the skin caused by a plant. The clinical patterns may be allergic phytodermatitis, photophytodermatitis, irritant contact dermatitis, pharmacological injury, and mechanical injury. In this article, we will focus mainly on allergy contact dermatitis from plants or allergic phytodermatitis occurring in Asia.     

Plant dermatitis

This review summarizes the major categories of plant dermatitis: (1) mechanical injury, (2) pharmacologic injury, (3) primary irritant phytodermatitis, (4) allergic phytodermatitis, (5) pseudophytodermatitis, (6) phytophotodermatitis, and (7) pseudophytophotodermatitis. Representative species from this classification are considered. Field characteristics, dermatitis produced, chemical constituents, and diagnosis are discussed.     

Durch Pflanzen ausgelöste toxische und allergische Dermatitis (Phytodermatitis)

Herbal products are being used increasingly for medical or cosmetic purposes. Many cosmetics contain plant extracts for fragrance. Sensitizing plants in cosmetics are tea tree oil, arnica, chamomile, yarrow, citrus extracts, common ivy, aloe, lavender, peppermint, and others. However, the sensitizing potential of these plants varies. Most of the sensitizing substances are sesquiterpene lactones or terpenes. The present paper reviews the various forms of phytodermatitis, including irritant plant dermatitis, phototoxic and photo-allergic dermatitis, allergic dermatitis, and airborne contact dermatitis.     

Clinical evaluation of patients patch tested with plant series: a prospective study

Background:

Plants are ubiquitous in nature and are essential for human life, though some do have detrimental effects. In India, there are various indigenous and foreign plants that are well known to cause dermatitis, Parthenium hysterophorus being the foremost.

Aims of the Study:

To study the clinical features of patients presenting with plant dermatitis and evaluate plant allergen series patch test results.

Materials and Methods:

50 patients with suspected plant dermatitis were evaluated regarding evolution of dermatitis, precipitating factors and contact with various plants. 31 patients (62%) complained of photo sensitivity and 24 (48%) had involvement of sun-exposed areas. Our provisional diagnoses included allergic contact dermatitis in 16, air borne contact dermatitis in 9, phytophotodermatitis in 7, photodermatitis in 6, airborne contact dermatitis to other causes in 4, phytodermatitis in 3. Patients were patch tested with Indian standard series of allergens as well as plant allergen series consisting of common allergenic plants of local flora in and around Manipal and also with plants strongly suspected by the patient. 35 tested positive with maximum positives (26 patients, i.e., 52%) to Parthenium hysterophorus (Compositae).

Results:

The result of patch testing was correlated with the history and clinical examination and relevance established.

Conclusions:

Majority of the patients with clinically suspected plant dermatitis belonged to 3^rd or 4^th decade and Parthenium was the leading plant allergen Sensitization to Leguminosae plants and Hopea ponga, seen in 9 cases, have not been reported earlier in literature.     

Toxic phytodermatitis caused by Euphorbia helioscopia L. (sun spurge)

A 6-year-old patient presented with linear erythema and bullae on the face. The lesions developed after playing with plants the day before. The plant was identified as Euphorbia helioscopia L. (sun spurge). The sun spurge belongs to the Euphorbiaceae plant family. These plants produce a typical milky juice that causes toxic reactions following contact with skin and mucous membranes. In the literature several cases of toxic dermatitis caused by plants of the Euphorbiaeae family have been described. The most important differential diagnosis of these skin lesions is the bullous phototoxic dermatitis caused by psoralens. Plant-induced toxic dermatitis is of increasing importance in dermatology. The exact determination of the causative plants is a prerequisite for the diagnosis of phytodermatitis.     

Toxische Phytodermatitis nach Kontakt mit Euphorbia helioscopia L. (Sonnenwend-Wolfsmilch)

A 6-year-old patient presented with linear erythema and bullae on the face. The lesions developed after playing with plants the day before. The plant was identified as Euphorbia helioscopia L. (sun spurge). The sun spurge belongs to the Euphorbiaceae plant family. These plants produce a typical milky juice that causes toxic reactions following contact with skin and mucous membranes. In the literature several cases of toxic dermatitis caused by plants of the Euphorbiaeae family have been described. The most important differential diagnosis of these skin lesions is the bullous phototoxic dermatitis caused by psoralens. Plant-induced toxic dermatitis is of increasing importance in dermatology. The exact determination of the causative plants is a prerequisite for the diagnosis of phytodermatitis.     

Allergic contact dermatitis from exposure to Grevillea robusta in New Zealand

There are a number of reports in the literature of allergic contact dermatitis as a result of exposure to the sawdust and plant parts of Grevillea robusta . While this tree is prevalent in New Zealand, there seems to have been no previous published accounts of contact dermatitis, although anecdotal evidence indicates that such cases may be common. Two brief case reports are provided regarding severe phytodermatitis to G. robusta among professional arborists in New Zealand. As with other common plants capable of inducing allergic contact dermatitis, greater awareness among arborists, orchardists, forestry workers, gardeners, and health professionals will likely result in a reduction of cases.     

Allergic contact dermatitis to plants: understanding the chemistry will help our diagnostic approach

Allergic contact dermatitis due to plants is common. Potentially allergenic plants and plant products are found in many everyday environments, such as the home, the garden, the workplace, and recreational settings. By improving our knowledge of allergenic plant-derived chemical compounds, we will be better positioned to identify novel allergens. We review the most relevant chemical allergens that contribute to plant allergic contact dermatitis and propose a clinical classification system based on 5 major families of chemical sensitizers: α-methylene-γ-butyrolactones, quinones, phenol derivatives, terpenes, and miscellaneous structures (disulfides, isothiocyanates, and polyacetylenic derivates). We also describe the different clinical pictures of plant allergic contact dermatitis and review currently available patch test materials. A better understanding of the specific allergens involved in plant allergic contact dermatitis will help to predict cross-reactivity between different plant species or families.     

Parthenium dermatitis in India: Past, present and future

Parthenium dermatitis is an immuno-inflammatory disease caused by Parthenium hysterophorus and is the commonest cause of plant dermatitis in India. It is caused by airborne dry and friable plant particles including trichomes, and the most important allergens responsible for allergic contact dermatitis are sesquiterpene lactones. The combined type IV and type I hypersensitivity to parthenium has been recently postulated. In sensitized individuals, it can cause a spectrum of clinical patterns, such as classical airborne pattern, chronic actinic dermatitis-like presentation, mixed pattern dermatitis, exfoliative dermatitis, widespread dermatitis, and other rare patterns. There is definite trend towards change from airborne pattern to chronic actinic pattern in natural history of parthenium dermatitis. Contact sensitivity to parthenium is everlasting, and hence the disease runs a chronic course with exacerbation during summers. Patch testing with acetone or aqueous plant extract is the simplest way of confirming parthenium contact allergy. Management includes avoiding contact with allergen, managing dermatitis with topical corticosteroids/tacrolimus, and other immunosupressives like azathioprine. In future, we expect parthenium dermatitis to become less prevalent due to rapid urbanization and possible development of new biological methods to eradicate the parthenium. Genetic factors associated with susceptibility to parthenium dermatitis need to be studied.     

RUBBER SENSITIVITY

The records of patients attending a contact dermatitis clinic have been examined to find the patterns of localization and chemical sensitivity to rubber. It has been found that rubber sensitivity is one of the common causes of contact dermatitis, and that the chemicals responsible for hand dermatitis differ from those responsible for foot dermatitis.     

Compositae dermatitis

Compositae dermatitis is an allergic contact dermatitis. The most important allergens in the Compositae family are sesquiterpene lactones (SL), which are present in the oleoresin fraction of leaf, stem, flower and possibly pollen. Compositae dermatitis is most frequently seen in middle-aged and elderly people in patterns reflecting airborne or direct contact with the allergens. The pattern typically starts in summer and disappears in the autumn or winter. Repeated exposure over many years may lead to a chronic and, at times, a disseminated pattern. Seasonal variation does not occur in occupational Compositae dermatitis. In addition to the classically described airborne pattern of face, 'V' of neck, hands and forearms, hand dermatitis is now recognized to be an equally common presentation. This variability of clinical features, and the frequent occurrence of atopic dermatitis and contact allergy to one or more compounds, highlights the need for routine patch testing with sesquiterpene lactone mix 0.1% (Thermal, Hamburg, Germany), combined with aimed patch testing with Compositae plants and extracts. Avoidance of the plants and plant extracts of this large family can be difficult due to its widespread occurrence in flower, herb and vegetable gardens, urban and rural weed population and native vegetation. Importantly, Compositae plant extracts are present in many cosmetics, shampoos, herbal creams and ingested herbal remedies and tonics.     

Protein contact dermatitis: myth or reality?

Protein contact dermatitis is a dermatosis which usually presents as a chronic eczema with episodic acute exacerbations a few minutes after contact with the offending allergen. Patch tests with the responsible allergen are usually negative, and the diagnosis can only be made by means of scratch or prick tests with the allergen. Sometimes, specific IgE antibodies can be detected in the blood. As there is considerable confusion about this entity, we have reviewed the cases reported in the literature.     

Occupational allergic contact dermatitis caused by decorative plants

12 cases of occupational allergic contact dermatitis caused by decorative plants were diagnosed in a 14-year period. The patients were middle-aged, and their average exposure time was 13 years. The plant families and plants causing occupational contact dermatitis were Compositae (5 patients: chrysanthemum, elecampane, gerbera, feverfew), Alstroemeriaceae (5 patients, Alstroemeria ), Liliaceae (4 patients; tulip, hyacinth). Amaryllidaceae (2 patients: narcissus) and Caryophyllaceae (2 patients; carnation, cauzeflower). The known chemical allergens causing dermatitis were tuliposide-A and sesquiterepene lactones, such as alantolactones and parthenolide, in the Liliaceae and Compositae families. 7 of the 12 patients were able to continue their work; 5 were not because of severe relapses of skin symptoms. The plant allergen and extract series currently available are of great help in the diagnosis.     

An antigen from Parthenium hysterophorus Linn.

The increasing incidence of contact dermatitis due to the wild growth of the weed Partheium hysterophorus Linn. in many parts of India has prompted chemical analysis coupled with clinical testing to isolate the offending agent. Results are present to show that parthenin, a sesquiterpene lactone, is the major antigen which produces contact dermatitis in sensitive human beings.     

Tomato contact dermatitis

The tomato plant (Solanum lycopersicum) is an important crop worldwide. Whereas immediate‐type reactions to tomato fruits are well known, contact dermatitis caused by tomatoes or tomato plants is rarely reported. The aims of this study were to present new data on contact sensitization to tomato plants and review the literature on contact dermatitis caused by both plants and fruits. An ether extract of tomato plants made as the original oleoresin plant extracts, was used in aimed patch testing, and between 2005 and 2011. 8 of 93 patients (9%) tested positive to the oleoresin extracts. This prevalence is in accordance with the older literature that reports tomato plants as occasional sensitizers. The same applies to tomato fruits, which, in addition, may cause protein contact dermatitis. The allergens of the plant are unknown, but both heat‐stable and heat‐labile constituents seem to be involved. The fruit contains fragrance compounds that are also present in Myroxylon pereirae (balsam of Peru), possibly accounting for cross‐reactivity. The proteins in pulp and peel may contribute to protein contact dermatitis. Until more is known about the allergens, the diagnosis of contact dermatitis caused by tomato plants and fruit may be established with the use of ether extracts and fresh fruits, respectively.     

Toxicodendron dermatitis in the UK

BACKGROUND: We present two cases of Toxicodendron dermatitis, one acquired in the United States but presenting in the United Kingdom (UK), the other a recurrent dermatitis following importation of the plant to the UK. Poison ivy, poison oak and poison sumac are native to North America and belong to the genus Toxicodendron. This group of plants is of interest to the dermatologist because they contain a mixture of potent sensitisers which cause a severe allergic contact dermatitis. CONCLUSIONS: The dermatitis can present to the dermatologist in Europe after an individual has been in contact with the plant whilst visiting an endemic area. The plants have the potential to grow in Europe and it is therefore possible for an individual to be sensitised and subsequently to develop the rash without leaving the continent.     

Dermatitis bullosa striata pratensis durch Ruta graveolens L. (Gartenraute)

A patient developed severe bullous phototoxic contact dermatitis caused by Ruta graveolens L. (garden rue) which belongs to the Rutaceae family. To date only a few cases of phototoxic reactions to the garden rue have been reported. The phototoxic components of Ruta graveolens L. are the fouranocoumarins 5-methoxypsoralen (bergapten) and 8-methoxypsoralen (xanthotoxine), and the furanoquinoline dictamnine whose phototoxic properties were recently discovered. Since the garden rue is frequently cultivated, it should be considered in the differential diagnosis of phototoxic phytodermatitis.     

The current status of the weed Parthenium hysterophorus L. as a cause of allergic contact dermatitis

The dissemination of allergenic plants as horticultural introductions, or in the case of the weed Parthenium hysterophorus L. apparently by chance, can have undesirable results. This species of the Compositae family, native to the Caribbean region, has spread widely in India, causing allergic contact dermatitis from its content of sesquiterpene lactones, and has recently appeared in Australia.
The clinical features consist of dermatitis of the exposed skin surfaces from direct contact with the weed, but resembling photo dermatitis. In fact, contact dermatitis from the plant can coexist with light sensitivity. The plant does not show phototoxic activity but may contain an unidentified photo allergen. Since plant hairs and the pollen contain sesquiterpene lactones, they can probably cause air bone contact dermatitis. Attempts to control spread of the plant have so far not been successful.     

Contact Dermatitis in Older Adults

Contact dermatitis is a significant health problem affecting the elderly. Impaired epidermal barrier function and delayed cutaneous recovery after insult enhances susceptibility to both irritants and allergens. Exposure to more numerous potential sensitizers and for greater durations influences the rate of allergic contact dermatitis in this population.Medical co-morbidities, including stasis dermatitis and venous ulcerations, further exacerbate this clinical picture. However, while these factors tend to increase the degree of sensitization in the elderly, waning immunity can actually decrease such a propensity. This interplay of both intrinsic and extrinsic factors makes a generalization on trends for contact dermatitis in older adults challenging. The literature has varying reports on the overall incidence of allergic contact dermatitis with advancing age. Nevertheless, it does clearly show that sensitivity to topical medicaments increases with age. Irritant contact dermatitis studies are more consistent, with less reactivity (to irritants) in older compared with younger skin. Diagnosis of both irritant and allergic contact dermatitis is based on a thorough history, complete skin examination, and comprehensive patch testing. The mainstay of therapy is avoidance of the offending chemical substances and the use of topical along with systemic therapies, depending on the severity of the condition.     

Skin disorders in amputees

BACKGROUND: Dermatologic problems restrict the normal use of a prosthetic limb. The importance of contact dermatitis to skin morbidity in a population of amputees and the selection criteria for patch testing have not been clearly defined. OBJECTIVE: We describe the range of dermatoses seen in a population of amputees and examine the incidence, causes, and patterns of contact dermatitis. METHODS: This is a questionnaire-based, cross-sectional study of 210 amputees. Those with a skin problem were assessed by a dermatologist. Patch testing was undertaken in patients with persistent dermatitis. RESULTS: A total of 34% of amputees experienced a skin problem. Lesions resulting from friction, pressure, and occlusion are common. Allergic contact dermatitis is seen in a third of patients with stump dermatitis. There are no features that distinguish allergic from irritant (chemical or physical) dermatitis. CONCLUSION: Dermatologic problems are common in prosthetic limb users. Allergic contact dermatitis is a significant problem, and all patients with dermatitis on the residual limb should be patch tested.