Is There a Medical Explanation?

Case 1: & Case 2:

CASE 1:

Figure 1A 13-year-old girl of African American descent is brought to the pediatrician's office becauseof a lesion on her neck. The girl's mother had telephoned the office before the visit, statingthat the lesion resembled a blister at first, but now looked like a burn.In the office, the girl is afebrile and not distressed. She explains that she awoke themorning prior to the visit with a blister on the right side of her neck. It gradually becamebigger, and she used cold washcloths to wipe it. The central area became more painful andthe skin layers peeled off, revealing a weepy, inflamed circular area (

Figure 1

). The burnis of second degree in the center and first degree in the surrounding tissue. There are noother skin findings, and the rest of the physical examination is normal.The mother is very upset by the finding but can offer no explanation. The girl repeatedlysays she does not know how the lesion occurred.

Case 2:

Figure 2

Figure 3An 11-year-old boy is brought by his mother to the pediatrician'soffice with a 1-day history of a rash on his shouldersand arms. His mother relates that he woke up withthe rash, and she was very concerned about how quicklyit appeared. The patient is a healthy boy who denies anyrecent illness, associated pruritus, trauma to the skin, oruse of any new products.Physical examination reveals macular, hyperpigmentedlesions on the boy's shoulders and upper arms. Theyappear in a similar pattern on both shoulders withoutvesiculation, petechiae, or bruising. The rest of the physicalexamination is normal.Because child abuse is suspected, photographs areobtained (

Figures 2

and

3

). Note the linear hyperpigmentedmarks in

Figure 3.

Have the children in these 2 cases been intentionallyharmed-or is there a medical explanation in bothcases for the lesions?

Case 1: and Case 2:DISCUSSION:Any injury without adequate explanation shouldraise the suspicion of abuse. When a verbal child isunable to explain an injury that apparently occurredon a relatively protected area of the body, such asthe neck, there is more reason to suspect abuse.In case 1, the lesion resembles a fresh burn,and no other medical explanation seems to fit thefindings in the history or physical examination.The child and parent were asked open-ended questionsabout how this burn occurred, but neithercould supply further information.In case 2, the hyperpigmented findings suggesta healed burn or unusual bruising pattern.The linear marks look like drip lines. In general,when an inflicted burn is suspected, a diagnosis dependson ascertainment of the following:

• Is there an adequate explanation?
• Is the child developmentally able to cause this injury?
• Does the lesion's morphology form a recognizablepattern?
• What are the dimensions and pattern of the lesion(s),and do these match the dimensions of a known object,such as a cigarette?
• Are there other signs of abuse?
• Are there other risk factors for abuse?
• What is the child's history? Is there a history of repeatedinjuries or burns? Is there a history of fire setting?
• What is the degree of the burn?
• If you suspect a scald burn, what temperature was thewater?
• How long ago do you suspect the lesion was inflicted(what is the stage of healing) and where were the caregiversat that time?

Possible causes of burns include flames, electricalcurrent, steam, hot substances, or chemicals. These can beclassified as thermal, electrical, chemical, or scald burns.Burns can be further classified by depth of injury. Firstdegreeburns are confined to the epidermis and involve minimaltissue damage. Most sunburns are first-degree burns.Second-degree burns or partial-thickness burns destroy theepidermis and part of the dermis and typically are painful.The possibility of a burn from a particular cause should beascertained before concluding that child abuse occurred.

CAUSE OF THESE "BURNS":PHYTOPHOTODERMATITIS

Case 1:

Here, the mother was thought to be deceptive becauseshe did not seem to offer any explanation for the lesion.However, further specific questioning regardingsome possible causes of burn revealed the diagnosis.Although the possibility of sunburn in this case wasunlikely (the girl has deeply pigmented skin and lives in anarea of the Northeast with little strong sunlight), we askedif she had been out in the sun. She reported that she hadbeen sitting on her porch the day before the lesion eruptedand specifically remembered feeling the heat of the sunon that side of her neck. Further questioning about use ofany lotions, creams, sprays, or other cosmetics on herneck ultimately led to the diagnosis. The patient reluctantlyreported that she had used her mother's new perfume(without her mother's knowledge) on the right side of herneck. The combination of the perfume and sunlight causeda phototoxic reaction: the result was phytophotodermatitis.

Case 2:

In case 2, the mother and patient were questionedin more detail once child abuse was added to the differential.The boy had been outdoors swimming the day beforethe rash appeared; his shirt was off all day. He was withfriends who were drinking a citrus fruit punch. The key tothe diagnosis was that one of his friends threw some of thedrink on him as a prank and he tried to wipe it off with atowel. Some juice apparently remained on his skin and randown his arm, creating a linear pattern. Because he kepthis shirt off all day, the psoralens in the citrus punch reactedwith the sunlight, creating a phytophotodermatitis.

PHYTOPHOTODERMATITIS:A CHILD ABUSE MIMIC

Phytophotodermatitis is an eruption on the skin thatis the result of a phototoxic reaction that occurs with exposureto sunlight after contact with certain plants, fruits, orchemicals. The resulting dermatitis can mimic a variety ofdiseases, including child abuse.

^1-3

Phytophotodermatitiscan also mimic contact dermatitis, infectious lymphangitis,atypical bruising, malignancy, erythema multiforme, andcellulitis. It is commonly mistaken for a type IV hypersensitivityreaction (poison ivy) or a chemical burn.

^1-3

Becausethe reaction occurs after contact with a photosensitizingagent on a sun-exposed area of the body, the resulting lesionmay be linear, may resemble a hand or drip mark, ormay suggest child abuse because of a bizarre shape.

³

Thedermatitis generally develops within 24 hours after exposure,but desquamation and denudation sometimes occurdays after exposure, making it more difficult to ascertain acause. The dermatitis generally has a benign character, butcan present as a partial-thickness burn, as in case 1.

⁴

Lime juice is a common cause of phytophotodermatitis;it contains furocoumarin (psoralen).

^5,6

Plants produce psoralensto protect themselves from predation or mechanicaldamage. The juice is often inadvertently dripped around themouth, face, or hands-or purposely applied in a misguidedattempt to prevent or treat bug bites, jellyfish stings, andother assorted ailments.

^7,8

The photobiological agent, psoralen,acts by inducing cross-linking of DNA strands on exposure to UV-A (320 to 400 nm) sunlight. Epidermal cells aredamaged, and erythema, edema, and bullae form acutely.Hyperpigmentation from stimulation of melanin canoccur with chronic or acute exposure; it resolves slowlyover several weeks to months. Humidity and moisture enhancethe reaction by increasing the percutaneous absorptionof the psoralens.

^1,4

The reaction is not an allergicprocess and therefore does not require prior sensitization;it causes direct damage to the skin.The diagnosis of phytophotodermatitis is frequentlymade in people who spend a lot of time outdoors (eg, florists,gardeners, and agricultural workers). Large amounts of furocoumariningestion may cause a severe generalized reaction.Psoralen has been used therapeutically to treat vitiligo andpsoriasis (ie, PUVA therapy).

⁴

Other members of the Rutaceae family (oranges,grapefruits, and lemons), as well as other plants (celery,parsley, parsnip) that contain furocoumarins, may causephytophotodermatitis (

Table

).

^1,2,5,8,9

Plants and essential oilsthat contain furocoumarin derivatives (psoralen, 8-methoxypsoralen,5-methoxypsoralen, and 4,5,8-trimethoxypsoralen)are implicated in phytophotodermatitis.

^4,8

Case 2 demonstrates the effects of a citrus juice andsunlight, producing hyperpigmentation in an unusual pattern.In case 1, the fragrance most likely contained oil ofbergamot, a psoralen-rich fragrance.

^8,10

The oil is obtainedfrom the rind of

Citrus bergamia

, a bergamot lime. Thephototoxic agent is bergapten (5-methoxypsoralen). Aphototoxic reaction from fragrances is called berloquedermatitis and is the most likely diagnosis in this child'scase. Berloque (derived from the French for trinket orcharm) is used to describe pendant streaks of pigmentationon the neck, face, arms, or trunk.

¹⁰

Most psoralencontainingfragrances have been removed from cosmeticsin the United States. However, colognes such as "FloridaWater" and "Kananga Water" may still be used for spiritualblessing, treating headaches, and personal hygiene.

¹¹

Exposure to psoralens does not cause a skin eruptionin the absence of exposure to ultraviolet light. Exposure toultraviolet radiation in wavelengths greater than 320 nm(UV-A) is necessary to cause the phototoxic reaction.

¹²

The intensity and duration of the light exposure increasethe intensity of response to the agent. The child in case 1was exposed to sunlight in the spring in the Northeast,which provided a very weak dose of ultraviolet light. It islikely that the dose of psoralens in the inexpensive fragrancewas very high to have caused a severe reactionwith such low intensity sunlight.Plants contain differing concentrations of phototoxicagents, depending on the geographic area, season, andyear of harvest.

^8,12

Patients present most often in the summerand in warmer climates because psoralen concentrationsare highest and people are outside with less clothing.

TREATMENT

Treatment of phytophotodermatitis is primarily symptomatic,and further therapy is often unnecessary. Coolcompresses, avoidance of the sun, and use of sunscreensand topical corticosteroids have been recommended. Topicalcorticosteroids early in the course of the clinical presentationmay reduce the inflammation and therefore limitthe hyperpigmentation.

^1,8

Silver sulphadiazine is effective for partial-thicknessburns.

⁴

Sunscreens should be applied to the area becausethe skin may remain sensitive for several months.Some dermatologists recommend depigmentationagents (ie, topical hydroquinone) for severe hyperpigmentedconditions.

¹⁰

References:

REFERENCES:

1.

Goskowicz MO, Friedlander SF, Eichenfield LF. Endemic "lime" disease: phytophotodermatitis in San Diego County. Pediatrics. 1994;93:828-830.

2.

Bergeson PS, Weiss JC. Picture of the month. Phytophotodermatitis. Arch Fam Med. 2000;9:585-586.

3.

Coffman K, Boyce WT, Hansen RC. Phytophotodermatitis simulating child abuse. Am J Dis Child. 1985;139:239-240.

4.

Lagey K, Duinslaeger L, Vanderkelen A. Burns induced by plants. Burns. 1995;21:542-543.

5.

Weber IC, Davis CP, Greeson DM. Phytophotodermatitis: the other "lime" disease. J Emerg Med. 1999;17:253-257.

6.

Dannaker CJ, Glover RA, Goltz RW. Phytophotodermatitis: a mystery case report. Clin Pediatr (Phila). 1988;27:289-290.

7.

Koh D, Ong CN. Phytophotodermatitis due to the application of citrus hystrix as a folk remedy. Br J Dermatol. 1999;140:737-738.

8.

Bowers AG. Phytophotodermatitis. Am J Contact Dermat. 1999;10:89-93.

9.

Ljunggren B. Severe phototoxic burn following celery ingestion. Arch Dermatol. 1990;126:1334-1336.

10.

Chew AL, Maibach H. Berloque dermatitis. Emergency Medicine Online Textbook. Available at:

http://www.emedicine.com/derm/topic52.htm

. Accessed June 27, 2003.

11

. Wang L, Sterling B, Don P. Berloque dermatitis induced by "Florida water." Cutis. 2002;70:29-30.

12.

Hipkin CR. Phytophotodermatitis, a botanical view. Lancet. 1991;338:892-893.