Dr Dinuksha De Silva1, Dr Aruna Wijewardena1
1Royal North Shore Hospital, Sydney, Australia
We present an unusual series of ‘lime burns’: three cases of bilateral hand blistering and erythema were recently referred to our unit at Royal North Shore Hospital. A seven-year-old girl presented in March 2016 after juicing 200 limes, and a five-year-old girl and her seven-year-old brother presented in March 2018 after picking and juicing limes in Byron Bay. The five-year-old girl experienced progression to a large fluid-filled bulla overlying the dorsum of the right hand and three metacarpophalangeal joints. All three children were exposed to sunlight following contact with limes. The injuries were equivalent to superficial dermal burns – was lime juice the culprit?
We conducted a literature review on phototoxic lime-induced dermatitis. Phytophotodermatitis is a term introduced by Klaber in 1942 to describe the reaction of skin to sunlight after contact with furocoumarin-containing plant species. The plants commonly implicated are limes and oranges (Rutaceae family); parsley and celery (Umbilliferae); and figs (Moraceae) (Wagner 2002). Skin reaction occurs after contact with the photosensitising agent and exposure to ultraviolet A radiation.
We report findings from our cases in the context of this review. Progression of the cases was largely consistent with the literature: erythema within 24 hours of lime contact, vesiculation at approximately 72 hours and exfoliation at 10-14 days. Subsequent hyperpigmentation may persist for 6-12 months, and fortunately scarring is rare in children (Wagner 2002). Specialised topical treatment may be required, and cases involving >30% body surface area should be managed in a burns unit (Raam et al 2016).
1. Klaber RE 1942, ‘Phytophotodermatitis’, Br J Dermatol, vol. 54, pp. 193–211.
2. Raam, R, CeClerck, B, Jhun, P & Herbert, M 2016, ‘Phytophotodermatitis: The Other “Lime” Disease’, Ann Emerg Med, vol. 67, pp. 554-556.
3. Wagner, AM, Wu, JJ, Hansen, RC, Nigg, HN & Beiere, RC 2002, ‘Bullous phytophotodermatitis associated with high natural concentrations of furanocoumarins in limes’, Am J Contact Dermat, vol. 13, no. 1, pp. 10–4.
Dinuksha is a surgical SRMO in the Burns and Plastic Surgery Department at Royal North Shore Hospital in Sydney.