SECTION EDITORS:

THOMAS W. MCGOVERN, M.D.

Dept. ofDermafolo~, Yale Universi~ School ofMedicine, ROOHowardAue., New Haven, CT 06519, Tel: 203-785-6808, Fax: 203-785-3315, Email: thomas.mcgoueouerneyale.edu

ANGELA GODBY BOWERS, M.D.

Dept. ofDermato/og~, UT Southwstem Med. Ctr., 5323 Ha? Hines Blad., Dallas, TX 75235-9069, Tel: 214-648-8806, Fax: 214-648-9292, Email: agodby@mednet.slr;med.edu.

Some people talk to plants. Fewer people think plants talk to them. We want to talk about plants, and we hope that you will not only want to listen, but also, perhaps, you will even occasionally talk to us about plants.

Plants can cause an array of reactions in members offimo supienr, and in the course of this quarterly feature, we will provide reviews and/or commentary on common reactions to common plants, uncommon reactions to uncommon plants, and many reactions in-between. Plants and their derivatives have the potential not only to harm the skin, but also to ameliorate skin disease, and we welcome papers that concern either of these aspects of plants. If an occasional column is not necessarily practical, we hope it will be enjoyable.

From the Yale Lhiuersip School ofMedicine, New Haoen, CT Address repn’nt requests to Thomas W McGouemn, MD., Michigan

Medical, P.C. Dermatolou, 1425Mzchigan NE, GrandRapzdr, MI 49503. Copytight 0 1999 by W.B. Saunders Compan~j I046-199x/99J1003-0009$10.00/0

Als troemeria L. (Peruvian Lily) Thomm W. McGovern

Alstroemerias are one of the most common plants that cause allergic contact dermatitis in floral work- ers. This colorful plant has gained great popularity among florists and their patrons. This concise re- view will help dermatologists to gain familiarity with this plant and show how to diagnose prob- lems that it may cause. Copyright 0 1999 by W.B. Saunders Company

T HE IMPETUS FOR this review was a visit to my local florist to purchase flowers for my

wife for Valentine’s Day. Always on the lookout for potential photo opportunities to produce slides to supplement my botanical dermatology talks, I noticed that my 42-year-old florist had fissured and lichenified thumb and index fingertips that were worse on his dominant right hand (Figure 1). My questioning revealed that he had been a florist for 12 years, and that he became sensitized toillstroeme- ria after about 5 years of working with the plant. “The rash resolves during vacations,” working with gloves was too cumbersome, and the plants were too popular for him to stop carrying them, so he has decided to live with the dermatitis. He kindly posed with his leaf-cutting knife and an Alstroemeria stem to show why the dermatitis is distributed as it was (Figure 2).

History The Peruvian lily derives its scientific name from Klas Alstroemer, a student of Carl Linnaeus.’ Alstroemer first obtained plant seeds from Peru in 1754, and the Dutch were the first to use Alstroeme- ria in the flower industry (in 1963), breeding the plant so they could harvest year-round flowers.2 Alstroemerias were first marketed in the United States in 1980 and rapidly grew in popularity because of their beauty and long-lasting qualities. Dermatitis caused byAlstroemeria was first noted in Europe in the early 1970s3x” and in the United

172 American Journal of Contact Dermatitis, Vol 10, LEO 3 (September), 1999:pp 172.176

dlstroemeria 173

Figure 1. Dominant right thumb (A) and index finger (B) demonstrating lissured, h>perkeratotic dermatitis in a 42-).ear-old florist allergic to Alstroemeria.

States in the 1980s.2 The chemical tuliposide A and its allergenic breakdown product, tulipalin A (alpha-methylene-gamma-butyrolactone), were first identified in tulips,5,6 and 5 years later in

Alstroemeria. 7

Figure 2. Hand position of florist cutting lower leaves off or Alstroemha ligtzc L. that demonstrates greatest contact with right thumb pulp and radial surface of right index finger accounting for dermatitis shown in Figure 1.

Botany The family Alstroemeriaceae is comprised of five genera and approximately 150 species. Sixty of these species belong to the genus Alstroemeria (which was once classified in the family Amaryllida- ceae) and are native to Central and South America, especially in the Andes.8 The compound tuliposide A is found in two genera, Alstroemeria and Bomarea. Although A aurantiaca D. Don has been in cultiva- tion for over 100 years, the primary species found in flower shops is Alstroemeria ligtu L. and its hybrids, which originated in Chile.‘,g These hardy flowers grow well in temperate climates and are cultivated today in South and North America and Europe.‘,‘O The starch-containing roots are edible.’

Figure 3. LUtuoenLe7ia ligtu L. Note slender stem (A) and flowers composed of three inner dappled, bicolored petals and three outer single-colored sepals (B).

174 Thomas W. McGovern

The colorful, delicate, trumpet-shaped flowers on slender, leafy 30 to 90-cm-long stems attract many buyers (Figure 3). The leaves are unusual, as they rotate 180 degrees while unfolding so that the original upper and lower surfaces are reversed. Alstroemerias come in numerous varieties that are available year round. They last longer than most cut flowers, with a vase life of up to 2 weeks, whereas each individual flower lasts 5 to 7 days.2,‘1 They come in about 30 different color shades derived from three main colors: red, pink, and yellow, and these may have streaks of purple, white, salmon, or apricot9 The inner petals are always bicolored and streaked or dappled (Fig- ure 3b) .*

As of 1996, Colombia provided the United States with 97% of imported alstroemerias; the Netherlands were a distant second (1.6%) (Society ofAmerican Florists, written communication, 3/29/ 99). Currently, 116 hectares of land in the Nether- lands is dedicated to the easy-to-grow alstroeme- rias, with 400 more hectares cultivated outside that country.” These very productive flowers yield 120-200 flower stalks per square meter.12

Contact Dermatitis to AIstroemeria Florists often remove flowers from the stems and thread wire through them. They also cut off the lower leaves that wilt more rapidly than the upper leaves and flowers (Figure Z), and this brings the fingertips in contact with the plant. Affected indi- viduals commonly present with involvement of the tips of the thumb, index, and middle fingers of the dominant hand more than the nondominant hand.13 Patients develop erythema, scaling, fissur- ing, pruritus, and tenderness primarily on the finger tips and pulps. *J~J~~‘*~‘~ In those who culti- vate alstroemerias, palmar hyperkeratosis and fis- suring is also common. I6 Typically, these patients do not develop vesicles and often have no itching, thus causing many physicians to dismiss allergic contact dermatitis as a possible cause of their eruption.

An identical pattern of dermatitis is seen in “tulip fingers” among handlers of tulip bulbs. Similarly, persons allergic to garlic develop greater involvement, but on the nondominant hand.’ As the reaction becomes more chronic, patients de- velop dermatitis on the hands and sometimes forearmsI Some patients develop facial dermati- tis from hand transfer, although this is uncom-

mon.12 The majority of patients develop no erup- tion beyond their fingertips. A number of case reports confirm that allergy toAlstroemeria typically requires up to 6 years of exposure before symp- toms develop.‘,2~10,‘*-~5,]7

Two articles reported urticarial reactions to Alstroemeria.‘s’2 In one case, the patient developed urticaria 2 days after her first contact with the plant.’ Primary irritant dermatitis has been docu- mented,12 and one case of depigmentation follow- ing flower handling and closed patch testing to plant parts’ has been attributed to an irritant reaction.t2 The depigmentation resolved within 2 months at sites of clinical contact but remained after 4 months at patch test sites.‘*

Epidemiology The Society of American Florists task force deter- mined that one-third of retail florist shops had at least one employee with hand dermatitis within the past year. I5 In affected shops, an average of 1 in 4 workers had dermatitis, suggesting that roughly 1 in 12 floral workers has hand dermatitis in a given year. Three studies of florists found 8, 10, and 12 workers with hand dermatitis.15J’~18 Of these 30 workers, 11 were allergic to Alstroemeria, suggesting that more than one-third (11 of 30) of florists with work-related hand dermatitis can attribute it to Alstroemeria. In each of these Ameri- can, I5 Italian IT and FinnishI studies, Alstroemeria > was the most common plant causing allergic con- tact dermatitis among florists. In the Finnish study, alstroemerias caused more severe clinical reactions than all other plants.‘* This allergenic plant may even cause dermatitis in a sensitized individual exposed for only a few seconds.‘g Many florists withAlstroemeria allergy respond by banning the flower from their shops.‘”

A Dutch study examined 153 workers who cultivated Alstroemeria.16 The incidence of hand dermatitis during the prior 12 months was 37% (based on history), whereas the point prevalence was 28% (based on clinical examination). Forty- eight patients with hand dermatitis were patch- tested to 0.005% tulipalin A in water, an alterna- tive to tuliposide, and 25 of 48 (52%) were sensitized to tulipalin A. They also showed that the period prevalence for hand dermatitis was 4 to 5 times greater among Alstroemeria workers than the gen- eral population. These authors used 0.005% tulip-

Alslroerneria 175

alin A in water, because it elicited stronger reac- tions than 0.01% tulipalin A in petrolatum. They found that workers with atopic dermatitis or wet hands or those who mechanically removed leaves with a knife were more likely to be sensitized. Pulling the leaves off manually was associated with a lower rate of sensitization.

Tuliposide Tuliposides A, B, and D are naturally-occurring bacteriotoxic substances found in plants of the Alstroemeriaceae and Liliaceae families.‘,20~21 Tuli- poside A hydrolyzes after skin, water, or acid contact to the unsaturated lactone tulipalin A (alpha-methylene-gamma-butyrolactone) and beta- D-glucose,‘~‘* whereas tuliposide B hydrolyzes to tulipalin B (beta-hydroxy-alpha-methylene- gamma-butyrolactone) and beta-D-glucose.‘* Tuli- palins A and B are fungitoxic as well as bacterio- toxic.‘* Tuliposides A and B are found in both the Liliaceae and the Alstroemeriaceae.20J23 Tulipo- side D is unstable and shows a tendency to cleave to &tuliposide A and tulipalin A in aqueous solu- tion at room temperature.20 None of the three tuliposides are allergenic, but tulipalinA and B are allergenic. 12:17.23 Therefore, tuliposides A and D both hydrolyze to the allergen, alpha-methylene- gamma-butyrolactone. Tuliposide B (and tulipalin B) lvere originally thought to be nonallergenic, or very weakly allergenic at best,’ leading Hausen to suggest breeding alstroemerias for low tuliposide A and high tuliposide B content.12 Unfortunately, three years after this article, Barbier and Benezra showed that tulipalin B (the beta-hydroxy deriva- tive of tulipalin A) could sensitize guinea pigs.23 They surmise that the negative patch test reac- tions to tulipalin B in tulipalin A-sensitive patients obtained by Slob et al.‘” were caused by a ten-fold greater tulipalin A content of the flowers. Thus, the patients were probably not yet sensitized to tulipalin B. Breeding alstroemerias for low tulipo- side contact may reduce the risk of sensitization,16 but the plants could become sensitive to bacterial and fungal attack. Although the sesquiterpene lactone allergens in the family Compositae con- tain an alpha-methylene-gamma-butyrolactone moiety, there is no cross-reactivity with tulipal- ins.25,26

Tuliposide A is found as 0.2% to 2.0% w/w of fresh alstroemerias in stems, leaves, and flow- ers.‘2,24 No published study has examined the

presence of tuliposide A in the roots. The flower petals contain the highest amounts of tuliposide A, and contact with them causes the most severe allergic reactions.1~12~22

Patch Testing Hausen et a1.12 recommend against patch testing with fresh plant parts or short ether extracts of the leaves and petals, because primary irritant reac- tions will usually ensue, and because active sensiti- zation is possible.12 In guinea pigs, the primary irritation threshold for tulipalin A was 10% in open epicutaneous tests and 1% under occlusion. All 10 guinea pigs tested with 1% tulipalin A were aller- gic to it one month later.12

Tulipalin A is unstable, being sensitive to heat and light, but it is stable in aqueous solution in the dark at 5”C.** Tulipalin A in petrolatum loses its reactivity after 2 weeks; however, the methanol extract maintains the allergen in a stable glycoside form that may be stored at room temperature when incorporated into petrolatum.‘2 Although Hausen et al. suggested 0.01% allergen (combina- tion of tuliposide A and tulipalin A) as the safe concentration to avoid primary irritant reactions, their actual data support using 0.1% as the pre- ferred concentration for patch testing, and, in- deed, 0.1% tuliposide A or tulipalin A in petrola- turn has become the standard for testing for

Alstroemeria allergy. 2,13,15z’8 Thiboutot et alI5 tested 24 control subjects to 0.1% tuliposide A in petrola- turn and found it nonirritating. Santucci et al.” did take Hausen’s advice, using 0.0 1% tulipalin A and elicited 3 + reactions in sensitized individuals.

Based on the above data and a written commu- nication from James Marks, MD (3/24/99), vvho has done much patch testing to Alstroemeria; 0.1% tulipalin A in petrolatum (ordered as alpha- methylene-gamma-butyrolactone) from Che- motechnique Diagnostics (Tygelsjo, Sweden; www. chemotechniquese) is the patch test allergen of choice. Alternatively, a small portion of stem, leaf, or petal can be crushed and occluded on the back or forearm for 48 hours, with a final reading performed at 72 to 96 hours.

Treatment and Prevention If contact with the plant is not avoided, treatment is virtually futile. Even if a sensitized florist does not contact the plant, as long as the plant is in the shop, contact may be made because of plant juice

176 Thomas W McGovern

present on scissors, clippers, table-tops, and vases.t3 However, because the rash is rarely seen beyond the fingertips, it is unlikely that much sensitization actually occurs from such secondary contact. Keep- ing the plant localized to one area of a shop and away from the sensitized worker may well help relieve the problem. In one treated patient, topical and oral corticosteroids were only somewhat help- fu1.2

The allergen penetrates vinyl gloves,*J3 but patch testing a sensitive individual through nitrile gloves was negative* in one instance, but positive through thin nitrile gloves in another (Frances Storrs, MD, oral communication, 3/23/99). It seems that thick, but not thin, nitrile gloves will block the egress of the sensitizer. DeHaan et a1.2i showed that nitrile gloves have a break-through time of approximately 4 hours for tulipalin A. Another patient wore rubber gloves while working with alstroemerias and still developed dermatitis,’ and this agrees with the work of DeHaan et al.*’ Verspyck Mijnssen suggested using a barrier cream with cysteine because he noted that when cysteine and tulipalin A were mixed, positive reactions did not occur in individuals known to be sensitive to alstroemerias,2’ but there is no known cysteine- containing barrier cream available. No one has reported if the barriers 5% quaternium- 1% benton- ite lotion (‘Ivy-Block’, Enviroderm Pharmaceuti- cals, Louisville, KY) or (Poison Oak-n-Ivy Armor Pre-exposure Lotion, Tee Laboratories, Albany, OR) ameliorate dermatitis in sensitized individu- als.

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