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Outdoor dining causing blisters: think infantile phytophotodermatitis

© BMJ Publishing Group Limited 2021. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A 5monthold boy was brought to the emergency department in June by his mother, with a 1day history of a progressive erythematous rash on his face, chest and hands with associated blistering (figure 1). The child was systemically well with no medical history. Detailed history revealed that a day before admission, he had been feeding himself mashed carrots and parsnips while sitting outside in the sunshine wearing only a nappy. As he was a ‘messy’ eater and it was very sunny, he subsequently had his bath outside. His parents first noticed the rash on his right hand the next morning. It progressed during the day to his left hand, face and midchest. By evening, he had developed blisters on his right hand. On examination, he had a well demarcated, erythematous rash with erosions distributed periorally, centrally on the chest and upper abdomen with small irregular patches on his thighs and shoulders. On his right hand, there were large tense bullae and areas of desquamation (figure 1). The rash was associated with perioral erythema and peripheral streaks in a bizarre configuration consistent with a linear drip pattern (figure 2). There was sparing of his posterior trunk, mucus membranes, palms and soles. Phytophotodermatitis was diagnosed based on the history of outdoor eating in sunshine and the streaky appearance of the rash in a distribution where psoralen containing food came into contact with his skin. The patient responded to treatment with topical betamethasone 0.025% to his chest and limbs, and hydrocortisone 1% to his face. The rash resolved with mild residual hyperpigmentation (figure 2). Phytophotodermatitis presents with erythema and bullae in an eccentric linear streaky configuration on sunexposed skin reflecting contact with the psoralen source. 2 It is an important diagnosis as it can masquerade as abuse. Rash characteristics can range from erythema, vesicles or bullae, often healing with hyperpigmentation. 4 The eruption