Images in Clinical Medicine

Phytophotodermatitis and Limes

Miriam Keltz Pomeranz, M.D., and Julie K. Karen, M.D.

N Engl J Med 2007; 357:e1July 5, 2007

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A 23-year-old woman presented to the emergency department with a 3-day history of a painful, erythematous, blistering rash across her sun-exposed skin. Before the onset of the rash, the patient had spent 2 days at the beach, where she had prepared mojitos (a cocktail of rum, mint, sugar, water, and limes). During the subsequent 24 hours, a burning erythema developed and later blistered. Physical examination revealed tender skin (Panel A) with vesicles (arrow) and tense bullae (arrowhead) atop erythematous, edematous plaques on her dorsal hands, forearms, and chest. Symmetric, discrete, erythematous patches studded with tiny vesicles were found on her back (Panel B). Phytophotodermatitis is a nonimmunologic, phototoxic reaction resulting from the activation of furocoumarins (photosensitizing botanical substances present in limes and other plants) by long-wavelength ultraviolet radiation (UVA). Since there was extensive involvement of both hands, the patient was transferred to a burn unit for local wound care and hydrotherapy. After the eruption resolved, the skin remained hyperpigmented for several months before fading.

Miriam Keltz Pomeranz, M.D.
Julie K. Karen, M.D.
New York University School of Medicine, New York, NY 10016
miriam.pomeranz@med.nyu.edu

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