Correspondence

Margarita Photodermatitis

N Engl J Med 1993; 328:891March 25, 1993

Article

To the Editor:

A 30-year-old man presented with burning, severe swelling, and blistering of his left hand. Two days earlier he had prepared a large quantity of margaritas, which entailed squeezing 5 dozen limes, after which he had sunbathed for the remainder of the afternoon. He had no history of any skin disorder. Physical examination revealed serosanguineous vesicles and bullae on an edematous and erythematous base on the backs of both hands, sparing the palms (Figure 1Figure 1Vesiculobullous Eruption of the Left Hand on an Erythematous and Edematous Base.). Patches of linear erythematous vesicles were also noted extending up the right forearm and on the back of the left foot. A diagnosis of phytophotodermatitis due to limes was made. The patient was treated with prednisone for 7 days, with resolution of the edema and pain within 48 hours.

Phytophotodermatitis1 is a phototoxic dermatitis that requires a photosensitizer and subsequent radiation. The photosensitizer must be present in sufficient quantities, and the wavelengths of the subsequent radiation must be within the photosensitizing compound's action spectrum. Phytophotodermatitis elicited by lime juice is caused by the absorption of furocoumarin, a lipid-soluble 8-methoxypsoralen, into keratinocytes and its covalent binding to keratinocyte DNA after exposure to long-wavelength ultraviolet A radiation. This reaction irreversibly damages the DNA and is clinically evident as erythema, burning edema, and vesiculation within 24 hours after exposure. Healing is heralded by desquamation of the necrotic epidermis and ensuing hyperpigmentation.

Phytophotodermatitis involving fruits and vegetables has been described most often as an occupational hazard among citrus workers and celery harvesters, because these foods contain high concentrations of furocoumarins2,3. Isolated cases have also been described after nonoccupational exposure. One of the largest outbreaks was reported among 12 children in a day camp who were making pomanders from limes4. A peculiar case of suspected child abuse was also reported in which a 14-month-old boy presented with a severe blistering and erosive eruption resembling a burn5. Further investigation revealed that the toddler had splashed lime juice on his bare chest.

This case of margarita photodermatitis typifies an extreme phytophotodermatitis due to limes and stresses the importance of obtaining an appropriate history of contact with causative agents, as dictated by the unique findings on physical examination.

Alan I. Abramowitz, D.O.
Kenneth S. Resnik, M.D.
Hahnemann University Hospital, Philadelphia, PA 19102

Kenneth R. Cohen, M.D.
333 South Allison Pky., Lakewood, CO 80226

5 References

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   De Leo VA, Harber LC. Contact photodermatitis. In: Fisher AA, ed. Contact dermatitis. 3rd ed. Philadelphia: Lea & Febiger, 1986:454-69.
   

2. 2

   Sams WM. Photodynamic action of lime oil (Citrus aurantifolia). Arch Dermatol Syph 1941;44:571-587
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3. 3

   Birmingham DJ, Key MM, Tobich GE, et al. Phototoxic bullae among celery harvesters. Arch Dermatol 1961;83:73-87
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4. 4

   Gross TP, Ratner L, Rodriguez OD, Farrell KP, Israel E. An outbreak of phototoxic dermatitis due to limes. Am J Epidemiol 1987;125:509-514
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5. 5

   Dannaker CJ, Glover RA, Goltz RW. Phytophotodermatitis. Clin Pediatr (Bologna) 1988;27:289-290
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