JGIM CLINICAL PRACTICE Clinical Images 1 1,2 Jesse Keiser Fitzpatrick, MD and Jeffrey Kohlwes, MD, MPH 1 2 Department of Internal Medicine , University of California San Francisco, San Francisco, CA, USA; Department of Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA. KEY WORDS: dermatology; photosensitivity; phytophotodermatitis. J Gen Intern Med 33(6):975 DOI: 10.1007/s11606-018-4315-z © Society of General Internal Medicine 2018 31-year-old man presented after 1 week of painless rash Based on patient history of mixing margaritas outdoors 2 days on his left hand. Examination revealed three non- prior to rash onset, he was diagnosed with phytophotodermatitis. blanching hyperpigmented macules with mild scaling (Fig. 1). Phytophotodermatitis is a common non-immunologic cutaneous reaction caused by topical exposure to furocoumarin compounds in the presence of sunlight. Furocoumarins in limes, carrots, celery, dill, fennel, figs, parsley, and parsnips sensitize epithelial DNA to ultraviolet light. Cutaneous reactions are limited to contact areas and are often delayed by 36–72 h. Diagnosis is challenging because of the ubiquity of photosensitizing agents and the delayed onset. Involvement of skin in direct contact with beverage glasses is common, as are Bdrip lines^ and even secondary hand imprints, which have been misdiagnosed as child abuse. Asymptomatic hyperpigmentation is the most common reaction, but exposure can lead to severe sunburn with blistering, which may require treatment in burn units. Treatment is symptomatic, with rash resolution in weeks, though hyperpig- mentation can persist for months. Avoidance of topical furocoumarins and protection of skin from over-exposure to sunlight are preventive. Corresponding Author: Jesse Keiser Fitzpatrick, MD; Department of Internal Medicine University of California San Francisco, San Francisco, CA, USA (e-mail: Jesse.email@example.com). REFERENCES Figure 1 Clinical image showing hyperpigmented macules with mild 1. Lankerani L, Baron ED. Photosensitivity to exogenous agents. J Cutan scaling over patient’s left hand. Med Surg. 2004;8:424–31. 2. Goskowicz MO, Friedlander SF, Eichenfield LF. Endemic "lime" disease: phytophotodermatitis in San Diego County. Pediatrics. 1994;93:828–30. Received August 25, 2017 3. Pomeranz MK, Karen JK. Images in clinical medicine. Phytophotodermatitis and limes. N Engl J Med. 2007;357:e1. Revised October 25, 2017 Accepted January 11, 2018 Published online January 29, 2018
Journal of General Internal Medicine – Springer Journals
Published: Jan 29, 2018
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