Exploring the mango-poison ivy connection: the riddle of discriminative plant dermatitis

A relationship between sensitivity to poison oak or poison ivy and mango dermatitis has been suggested by previous publications. The observation that acute allergic contact dermatitis can arise on first exposure to mango in patients who have been sensitized beforehand by contact with other urushiol-containing plants has been documented previously. We report 17 American patients employed in mango picking at a summer camp in Israel, who developed a rash of varying severity. All patients were either in contact with poison ivy/oak in the past or lived in areas where these plants are endemic. None recalled previous contact with mango. In contrast, none of their Israeli companions who had never been exposed to poison ivy/oak developed mango dermatitis. These observations suggest that individuals with known history of poison ivy/oak allergy, or those residing in area where these plants are common, may develop allergic contact dermatitis from mango on first exposure. We hypothesize that previous oral exposure to urushiol in the local Israeli population might establish immune tolerance to these plants.     

FS11.5Toxicodendron dermatitis in the United Kingdom

We describe two cases of Toxicodendron dermatitis, one acquired in the United States but presenting in the United Kingdom, the other a recurrent dermatitis following importation 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. 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 the UK and it is therefore possible for an individual to be sensitised and subsequently to develop the rash without leaving the UK. A 35‐year‐old American man who lived in the UK visited his family in Marietta, Georgia USA. Shortly before his return to the UK he cut some plants back in his mother’s garden. Two days following his arrival back in the UK he developed a widespread pruritic and painful vesicobullous eruption. He required admission for intensive potent topical corticosteroid therapy and the eruption settled over the next two weeks. The plant he had been pruning was subsequently identified as poison sumac (Toxicodendron vernix). A 54‐year‐old woman living in Wales was referred to the Contact Dermatitis Investigation Unit because during the summer months for the previous four years she had experienced an intermittent, intensely pruritic, vesicular and in parts linear eruption affecting her face, arms and legs. This responded slowly to potent topical corticosteroids. She is a keen gardener and suspected that it was related to a plant in her garden. She was patch tested to our Standard Series, Plant Series and all the plants in her garden. She showed ++ allergic reactions to sodium metabisulphite, propolis and a strong vesicular reaction to the leaf of one of the plants from her garden Inspection of the plant revealed that it had three leaflets per stem. She had taken a cutting whilst visiting friends in Pennsylvania in 1996 and on returning to the UK had planted it in her garden. It grew but had never flowered or produced seeds. Once the cause of her dermatitis had been confirmed our patient took the necessary protective measures and removed the plant including its roots from her garden. She has not experienced any further problems with her skin. She contacted her friends in the USA who knew precisely where she had picked the plant. A further specimen was taken to the local Conservation Office where it was confirmed to be poisonivy. Poison ivy and poison sumac belong to the genus Toxicodendron which is native to North America and Mexico. They cause an allergic contact dermatitis when there is exposure to a bruised portion of the plant. This leads to the oleoresin, urushiol coming into contact with the skin. 25–60% of North Americans are reported be allergic to poison ivy and its relatives. The importation of plants into the UK is restricted by law. It is clear that this plant grew in its new habitat but did not extend beyond the confines of the garden. With frequent and more extensive air travel it seems reasonable to speculate that similar occurrences have taken place and that plants not endemic to Europe should be considered in those with suspected plant dermatitis.     

Is it,or isn't it? Poison ivy look-a-likes

Poison ivy causes more allergic contact dermatitis (ACD) than any other cause. Although physicians rightfully focus on the treatment of the dermatitis, prevention will be aided by recognition of the foreboding plant. Likewise, many other plants can masquerade as poison ivy and cause one to needlessly curtail his or her activities because of fear of a bad reaction. The most common poison ivy pretenders in the United States are discussed, and distinguishing plant characteristics are highlighted.     

Hyposensitization to poison ivy after working in a cashew nut shell oil processing factory

19 adults were patch tested to urushiol, the allergen in poison ivy/oak, to determine their sensitivity to this allergen after working in a cashew nut shell oil (CNSO) processing plant. The cashew nut tree and poison ivy/oak are in the same botanical family. Anacardiaceae, and they share similar chemicals which cause allergic contact dermatitis. 13 of the 19 workers had a preemployment history of poison ivy sensitivity, with 10 developing CNSO dermatitis. After working in this factory for several months, 9 of the 13 noticed a decreased sensitivity or no sensitivity to poison ivy/oak. When tested to urushiol extract, only 3 reacted positively, 2 minimally. These results imply that hyposensitization to poison ivy/oak occurred in these employees after development of hardening to cashew nut shell oil.     

Dissociative identity disorder presenting as dermatitis artefacta

Dermatitis artefacta is a rare psychiatric condition characterized by rubbing of skin blisters and denial of self-infliction. Dissociation may be comorbid with self-injurious behavior. A background of emotional disturbances during formative years and in later life often results in feelings of isolation and insecurity, which can lead to dissociation as a primary defense mechanism used to overcome traumatic events. In this case report, we describe a female patient with dermatitis artefacta associated with dissociative identity disorder. The patient was a 14-year-old girl. Multiple large, deep ulcerations with unnatural shapes were seen on her left forearm. The ulcerations were thought to be self-inflicted. Psychiatric examination revealed that she had a different identity, and inflicted the lesions when this was assumed. This case leads us to suggest that patients with dermatitis artefacta might have comorbid dissociative experiences, which cannot be identified easily.     

Black-spot poison ivy dermatitis. An acute irritant contact dermatitis superimposed upon an allergic contact dermatitis

A black spot in the epidermis over a blister of poison ivy dermatitis is an uncommon finding. Four patients with the phenomenon are described. Histologic and histochemical studies were made on biopsy material and the blackish deposit on the skin surface was compared with black deposits in and on leaves of the species of poison ivy. This examination revealed a yellow, amorphous substance on the stratum corneum of the lesions and a similar substance in and on leaves of the poison ivy plant, Toxicodendron radicans ssp. negundo. Associated with the pigmentary deposits there were distinct changes of acute irritant contact dermatitis superimposed upon allergic contact dermatitis. Our findings support the view that the black material is the oleoresin of the plant, and that this substance behaves both as an irritant and an allergen.     

Toxicodendron radicans dermatitis with black lacquer deposit on the skin

Four patients with clinical Toxicodendron dermatitis (poison ivy) presented with dramatic black lacquer-like deposits on several lesions. This black deposit was also observed at sites of injury on poison ivy plants and was reproduced on volunteers by the application of plant sap on the skin. Histologically, the observed material was identified in the stratum corneum. This little-recognized phenomenon has been mentioned in past dermatologic literature.     

Toxische Kontaktdermatitis auf Poison Ivy in einem Privatgarten in Deutschland

A couple suffered for 5 years from recurrent eruptions with vesicles and bullae after contact with an unknown "climbing weed" in their private garden in Germany. After this plant was identified as poison ivy and eradicated, their skin problems were solved. This is the first report of poison ivy in this setting. Urushiols in poison ivy are not only strong allergens but also potent irritants. Negative patch tests in the husband suggest that the bullous dermatitis was a toxic reaction.     

Diagnostic clues to dermatitis artefacta

We report a case of dermatitis artefacta in a 36-year-old man who had progressive, nonhealing ulcers and swelling of his right arm. The lesions spared two tattoos. In addition, our patient had several of the classic features of dermatitis artefacta. We outline more than a dozen diagnostic clues that may help the clinician faced with this difficult problem.     

Black spot poison ivy: A report of 5 cases and a review of the literature.

Black-spot poison ivy dermatitis is a rare manifestation of a common condition. It occurs on exposure to the resins of the plants of the Rhus family also known as Toxicodendron. We describe 5 patients with black deposits on their skin and clothing after contact with poison ivy and review the literature reflecting different aspects of this phenomenon including clinical presentation, histologic findings, and historical background.     

A case of bullous dermatitis artefacta possibly induced by a deodorant spray

Dermatitis artefacta is one of a spectrum of factitious diseases etiologically responsible for skin lesions denied by patients. These factors often make it difficult to identify the causative agents of the condition. Herein, we report a case of bullous dermatitis artefacta in a 12-year-old girl, for which a deodorant spray was suspected as the probable cause. Pathological examination revealed subepidermal blistering with full-thickness necrosis of the epidermis, suggesting a thermo- or cryo-induced injury. Psychological testing demonstrated her immaturity and dependence. In searching for the causative agent, we suspected a deodorant spray as a blister-inducing agent. We succeeded in reproducing a similar blister lesion on the volunteer's healthy skin using the same spray. Psychiatric involvement significantly complicates the treatment of factitious diseases, including dermatitis artefacta. Cooperation among dermatologists, psychiatrists and the patient's family members is required for ensuring a favorable prognosis.     

Poison ivy/oak dermatitis. Use of polyamine salts of a linoleic acid dimer for topical prophylaxis

Closed patch tests were used to evaluate the ability of 156 different preparations (based on 22 different chemicals) to prevent poison ivy dermatitis. Several polyamine salts of a linoleic acid dimer were identified that were totally able to prevent the usual dermatitis in approximately 70% of subjects. The effectiveness of the preparations improved when the antigen and the protectant were washed off within eight to 12 hours, instead of remaining on the skin for 48 hours. When washed off, and depending on the protectant, concentration, and vehicle used, several of the preparations were totally able to prevent a dermatitis in a range of 56% to 100% of subjects tested. Further work with these compounds may greatly benefit the many people currently plagued by their allergy to poison ivy and poison oak.     

Squamous cell carcinoma in a patient with Netherton's syndrome

A 29-year-old white woman with a history of Netherton's syndrome presented with two squamous cell carcinomas on the right dorsal hand and the left upper arm. She reported a 2-year history of these lesions, which were originally treated as warts. She denied excessive sun exposure, immunosuppressive therapy, or a previous history of skin cancer. Her past medical history included acute renal failure, multiple urinary tract infections, meningitis, and recurrent otitis media as a child. In addition, she had an ovarian abscess at 4 years of age with resulting salpingo-oophorectomy. She also reported a history of severe myopia, glaucoma, and multiple ocular infections with a resulting corneal scar. In addition to atopic dermatitis, she had a 10-year history of psoriasis. Her medications included topical steroids and emollients for atopic dermatitis and psoriasis, in addition to Timolol ophthalmic drops for glaucoma. Her family history was significant for a 22-year-old sister with Netherton's syndrome (Fig. 1). She denied any history of skin cancer in her sister or other members of her family. On physical examination, she had an exfoliative erythroderma, madarosis, and diffuse patchy alopecia. In the bilateral axilla, she had well-defined pink scaly plaques which were confirmed as psoriasis by biopsy. On the right dorsal hand, she had a 1.5 x 1.0 cm pink verrucous plaque (Fig. 2). On the left upper arm, she had a 1.5 x 0.8 cm pink scaly plaque. Biopsies of both sites confirmed squamous cell carcinomas. Both lesions were completely excised with 4 mm margins.     

Topical prevention of poison ivy/oak dermatitis

An organoclay preparation was evaluated for topical protection against experimental poison ivy/oak in a rigorous double-blind study. By direct comparison with the same subject, it proved more effective than comparable preparations of bentonite, kaolin, or silicone in 16 of 17 trials. When evaluated globally against control responses to urushiol the organoclay preparation gave 95.3% protection against topical urushiol applications, ranging from 4.75 to 0.0475 nmol. Bentonite, kaolin, and silicone gave 29.6%, 37.9%, and 32.9% protection, respectively, in the same system. We conclude that organoclay is an effective topical protectant against experimental poison ivy/oak dermatitis, and deserves further clinical evaluation.     

DERMATITIS ARTEFACTA AND SEXUAL ABUSE

Case 1 : This 16-year-old woman was referred for psychiatric management of her dermatitis artefacta that presented as superficial linear abrasions on her thighs and arms. During psychotherapy, the patient disclosed that her father had started sexually molesting her when she was about 8 years old. By age 10 years her father was having sexual intercourse with her. Initially, the patient confused her father's sexual advances with affection, but by age 10 years she became acutely aware of the abusive nature of their relationship. At this time, the father threatened to leave the family if the patient disclosed the sexual abuse. This was very threatening for the patient, since it would mean that her mother and her siblings would end up on welfare. The father then blamed the patient for “seducing him” and continued to abuse her sexually; the patient felt guilty and “bad.” The patient started making superficial linear abrasions on the anterior aspects of her thighs. She described that it helped her “release tension” because the pain helped her to cope with her guilt. The patient was essentially “punishing herself” by inflicting the lesions on herself. The patient also felt “very fat and ugly” and the scars on her body helped to validate this. During the course of therapy, the patient had much difficulty coping with the unresolved anger that began to surface as she acknowledged her feelings regarding the sexual abuse. Initially, she could cope with her anger only by cutting herself, and the symptoms of her dermatitis artefacta became worse. After about 1 year of psychotherapy she was able to acknowledge her feelings more effectively and became much more assertive. This was associated with a marked decrease in the frequency of her self-mutilative behavior. Case 2 : This 29-year-old woman was referred for psychiatric management of her dermatitis artefacta. The patient would typically present to her family doctor with rectangular abrasions on her forearms. The self-inflicted nature of the lesions was obvious on inspection, but the patient denied remembering that she caused the injury. The patient entered psychotherapy once weekly, and after approximately 6 months, she began to have flashbacks about being sexually abused regularly by an older brother when she was between ages 5–8 years. The patient described dissociative experiences when she was being subjected to the abuse. For example, she felt like “she was watching someone else being abused” and remembers “not feeling anything” while her brother was raping her. Over several months she was able to recognize that she would dissociate whenever faced with emotionally disturbing situations, especially those involving anger. During these dissociative states she would inflict the rectangular abrasions on herself. The patient experienced a significant improvement in the frequency of her dissociative experiences and her self-mutilative behavior as she acknowledged her anger toward her brother more directly. Chlorpromazine, 25 mg qid, prn, also proved to be a valuable adjunct in her therapy, as it helped her to cope with her very strong anger, and decreased the frequency of her dissociative reactions.     

Dermatitis artefacta in a patient affected by impulse control disorder: case report

Dermatitis artefacta is a disease characterized by self-inflicted skin lesions in fully aware patients. Mechanical and chemical devices are most commonly used to produce such injuries. Several psychological disorders like depression, obsessive compulsive disorders, hysteria, etc. are associated with this kind of disease. Most of the patients are young females aged between 15 and 30, but the diagnosis of dermatitis artefacta may even be made in pediatric patients or elderly people. Because of its rarity and the polymorphism of lesions, dermatitis artefacta is often a challenge for the clinicians. More difficulties might be due to the lack of cooperation in these patients, who usually refuse the dialogue with doctors and deny their primary role in damaging their skin. We present a case of an elderly woman who showed a peculiar pattern of deep excoriating lesions disseminated on the upper part of her body, with an evident state of depression. Diagnostic and therapeutic procedure, that is often long lasting and difficult in such cases, was made by teamwork of dermatologists, psychiatrists and psychologists, leading to steady control of impulses and full remission of cutaneous symptoms.     

Induction of tolerance to poison ivy urushiol in the guinea pig by epicutaneous application of the structural analog 5-methyl-3-n-pentadecylcatechol

Previous studies have established that epicutaneous application of 5-methyl-3-n-pentadecylcatechol (5-Me-PDC), a synthetic analog of a poison ivy urushiol component, leads to immune tolerance to 3-n-pentadecylcatechol (PDC) in mice. The induction of tolerance by 5-Me-PDC may be mediated by a protein conjugate formed via selective reaction of thiol nucleophiles present on the carrier macromolecule with the corresponding o-quinone derived from the parent catechol. In order to examine further the tolerogenic properties of 5-Me-PDC, we have extended our studies to the guinea pig, the generally accepted experimental species for the study of contact allergy. The results have established that specific immune tolerance to poison ivy urushiol is induced following 2 epicutaneous applications of the PDC analog. Furthermore, we were able to show that the treated animals remained tolerant for at least 6 weeks, a period of time comparable to that observed following the intravenous administration of the O,O-bis-acetyl derivative of PDC. The data point to the possibility of developing a therapeutically effective topical tolerogen for poison ivy contact dermatitis.     

Treatment of toxicodendron dermatitis (poison ivy and poison oak)

Toxicodendron dermatitis results from a reaction to an oil soluble oleoresin that is present in many parts of the poison ivy and poison oak plants. Prophylactic measures include avoidance, protective clothing, barrier creams and hyposensitization. Treatments include washing the area immediately with a solvent suitable for lipids and the use of anti-inflammatory agents, especially corticosteroids.     

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.     

Quantitation and cloning of human urushiol specific peripheral blood T-cells: isolation of urushiol triggered suppressor T-cells

A limiting dilution assay was developed to quantitate urushiol (the antigen of poison ivy; Toxicodendron radicans) specific T cells from peripheral blood of a patient with a history of rhus (poison ivy) dermatitis. It was found that maximal sensitivity with minimal nonspecific proliferation could be produced with the use of 5 U/ml of recombinant IL2 added to the assay on day 6. This donor was found to have a frequency of urushiol specific peripheral blood T cells of (1/2935). Five interleukin 2 (IL2) dependent urushiol specific T-cell clones were generated from the peripheral blood of this patient. These T-cell clones had a CD8+ (T8+) phenotype and proliferated specifically to both extracts of Toxicodendron radicans (poison ivy) leaves and pure urushiol. Pentadecylcatechol was an inferior antigen, only stimulating proliferation of one clone. The ability of all clones to proliferate to pure urushiol, despite their having been induced with leaf extract, suggests that urushiol, or closely related catechols, represent the only allergenic constituents of Toxicodendron radicans. Lymphokine production in response to antigen varied between (0.6-5.0) units/ml of interleukin 2 (IL2) and (1.0-120) units/ml of gamma interferon. Although none of the clones showed significant cytotoxicity against NK targets, three of five lines showed considerable cytotoxicity against concanavalin A treated (lectin approximated) targets. However, cytotoxicity for rhus conjugated autologous targets was not detected. It was found that several of these CD8+ clones could suppress IgG production in the presence of rhus antigen. The isolation of these T-cells from peripheral blood several months after rhus dermatitis suggests that these clones may have a role in down regulating delayed hypersensitivity to urushiol.