Allergol et Immunopathol 1999;27:29-31.
CLINICAL CASES
Primula dermatitis
R. Lleonart Bellfill, R. Casas Ramisa, and S. Nevot Falcó
Allergy Unit. Hospital General de Manresa.
SUMMARY
We report the cases of 2 patients diagnosed as having primula dermatitis. Both patients were housewives who had been exposed to primula plants. Although only one related her clinical manifestations with looking after plants, the symptoms of both remitted when contact with primula was avoided. The diagnosis was carried out with a patch test concentration of 0.01% primin pet.
As primula dermatitis has variable clinical manifestations that can not easily be related to contact allergy, we emphasize the need to include synthetic primin in our standard patch test series.
Key words: Primula. Allergy. Primin. Patch test.
RESUMEN
Presentamos dos mujeres, amas de casa, sin antecedentes personales o personales de atopia, que referían episodios de eritema pruriginosa en las manos, antebrazos y cara de meses de evolución. Una de las pacientes relacionaba los síntomas con la manipulación de flores, mientras la otra no refería ninguna relación. Las pruebas epicutáneas con la batería estándar Europea (Hermal-Trolab) demostró en las dos pacientes una monosensibilización a Primina 0,01% pet. Los síntomas remitieron en ambas pacientes al cesar el contacto con Primula.
La primina no se halla presente en la batería estándar del GEIDC (grupo español de investigación en dermatitis de contacto). Consideramos que se debería replantear su inclusión por la gran presencia de Primula en casas y jardines y la existencia de sensibilizaciones relevantes cuyo origen pasa inadvertido.
Palabras clave: Primula. Alergia. Primina. Pruebas epicutáneas.
INTRODUCTION
Primula is a plant family with more than 500 species, most of which are indigenous to the temperate zones. They have colorful early blossoms that make them ideal for gardens (1).
Many cases of allergic contact dermatitis caused by Primula obconica have been described. Contact dermatitis may be direct or airborne. Cases of photodermatitis (2) or herpes-like (3) lesions have also been described. Primula obconica contains the potent sensitizer primin.
European standard series of patch tests include synthetic primin 0.01% pet, but primin is not included in the Spanish or North American series (4).
PATIENTS AND METHOD
Case 1: A 57-year-old, non-atopic housewife who suffered dermatitis of the face, arms, and forearms after coming into contact with primula flowers.
Case 2: A 55-year-old, non-atopic housewife, who had episodes of hand and thorax erythema and pruriginous facial angioedema with no apparent relation.
The patch test procedure recommended by the ICDRG was carried out using Leukotest® and Leucofix® (Beiersdorf AG, Hamburg, Germany). The application time for the European standard series and synthetic primin 0.01% pet (Hermal-Trolab) was 2 days. Readings were made at 48 and 72 hours.
RESULTS
Patch tests with synthetic primin were positive (++) in both patients. None of the other allergens elicited any reaction (Fig. 1).
Figure 1.--Positive patch tests for primin 0.01% pet after 48 h.
Once contact with primulas was avoided, the symptoms of the two patients remitted completely.
DISCUSSION
Many cases of plant dermatitis are occupational (florists, gardeners). Primula dermatitis is the main cause of non-occupational plant dermatitis in Europe, with a prevalence ranging from 0.3% to 1.8% (5). It affects mainly housewives. Primula dermatitis has a variable clinical picture that cannot easily be related with contact allergy (6). The most common clinical manifestation is facial dermatitis in combination with hand and/or forearm dermatitis (7). Sometimes, as in our patients, facial edema is more prominent than eczema and the diagnosis of contact dermatitis may be more difficult. Our second patient did not identify any relation between her dermatitis and contact with primulas. However, when contact with the flower ceased, her symptoms disappeared rapidly.
The sensitizing substances of many plants are present mainly in oleoresin fraction. Primin (6-methoxy-2-n pentyl-benzoquinone) is the main allergen (8) in Primula, but other allergens, such as micodin, are present (9). The amount of allergen formed by Primula varies considerably with the season, method of cultivation, and horticultural variety. Standardization of patch testing by using synthetic primin reduces the risk of irritant reactions and eliminates the differences in allergen concentration found between extracts.
The use of primulas as ornamental plants in homes and gardens is increasing (Fig. 2). The diverse patterns of Primula dermatitis and the difficulty of recognition by patients may obstruct diagnosis. However, Primula probably should be included in the standard screening battery, at least in those geographic regions of Spain where primulas are abundant.
Figure 2.--Primula obconica''s colourful flowers.
REFERENCES
1. Font Quer P. Plantas medicinales. Barcelona: Labor; 1987. p. 519-21.
2. Ingber A. Primula photodermatitis in Israel. Contact dermatitis 1991;25:265-6.
3. Thomson KF, Charles-Holmes R, Beck MH. Primula dermatitis mimicking herpes simplex. Contact dermatitis 1997;37:185-6.
4. Lachapelle JM, Ale SI, Freeman S, Frosch PJ, Goh CL, Hannuksela M, et al. Proposal for a revised international standard series of patch tests. Contact dermatitis 1997;36:121-3.
5. Ingber A, Menné T. Primin standard patch testing: 5 years experience. Contact dermatitis 1990;23:15-9.
6. Virgili A, Corazza M. Unusual primin dermatitis. Contact dermatitis 1991;24:63-4.
7. Tabar AI, Quirce S, García BE, Rodríguez A, Olaguibel JM. Primula dermatitis: versatility in its clinical presentation and the advantages of patch tests with synthetic primin. Contact dermatitis 1994;30:47-8.
8. Hausen BM, Heitsch H, Borrmann B, Koch D, Rathmann R, Richter B, et al. Structure-activity relationships in allergic contact dermatitis. Contact dermatitis 1995;33:12-6.
9. Krebs M, Christensen LP. 2-methoxy-6-pentyl-1,4dihydroxibenzene (miconidin) from Primula obconica: a posible allergen? Contact dermatitis 1995;33:90-3.
Correspondence:
R. Lleonart Bellfill
Hospital General de Manresa
La Culla, s/n
08240 Manresa, Spain
