It started as innocent backyard fun as two young kids reached for limes off a nearby tree and had a great time chopping them up into their very own lime juice. They spent hours playing in the sun (with plenty of sunscreen), jumping in and out of the pool to wash the juices off. What followed, was days in and out of the hospital as the children’s skin reacted to the combination of citrus and sunlight, causing a relatively unknown condition known as Phytophotodermatitis.

Phytophotodermatitis, colloquially known as Margarita burn, is a phototoxic reaction that occurs when skin comes into contact with certain plant chemicals and is subsequently exposed to ultraviolet (UV) light. This article explores a recent case from Australia where children suffered severe skin reactions after handling lime juice during outdoor play. Through this case study, we aim to shed light on the risks associated with phytophotodermatitis, highlighting the importance of awareness and preventive measures to protect unsuspecting adults and children from the devastating effects.

Two young children, both aged 8 years, were enjoying a Sunday afternoon barbecue at a friend’s place with their siblings. With their parents’ knowledge, they were chopping up the limes they had freshly picked from the tree and squeezing the juice into glasses, with plenty of overflow down their legs and skin.

The exposure to lime juice, combined with sunlight exposure, led to a series of distressing symptoms over the following days. Initially, the children developed a burning sensation on their skin and complained of “burning hands” as they woke the following morning. This quickly escalated throughout the day with the formation of rashes. Over time, these rashes intensified, culminating in significant blistering. This case highlights the acute sensitivity of skin to certain plant-based substances when exposed to ultraviolet light.

After trying a round of steroids prescribed by their GPs to treat ‘contact rash’ (assumably from a plant in the backyard, the parents presented to an Emergency Department on Day 3 with concerns over the growing blisters and pain. The initial response to the children's symptoms by local healthcare professionals was again to diagnose a contact rash and treat with further steroids. The specific condition of phytophotodermatitis was not immediately recognised, even when brought to the healthcare workers’ attention. This is thought to be due to the extensive nature of the rash, which isn’t commonly seen with ‘Margarita burn’. This reaction is often seen on the fingers of those who have made margaritas (made with lime) in the sun - hence the colloquial name for it.

It was only after a thorough review of the children's recent activities, which involved extensive use of lime on their skin, that a correct diagnosis was established. Subsequently, appropriate treatment measures were administered, focusing on alleviating symptoms and preventing further skin damage.

Lime juice contains compounds known as furocoumarins, which are photosensitive chemicals. When these chemicals come into contact with the skin and are subsequently exposed to UV light, they undergo a biochemical reaction that increases the skin's sensitivity to sunlight. This reaction leads to cellular damage and an inflammatory response. The damaged cells manifest as severe dermatitis, evidenced by symptoms such as burning, rashing and blistering.

To prevent incidents like phytophotodermatitis, education on plant and fruit sensitivities to sunlight is crucial. Parents and caregivers should be informed about the risks associated with exposure to certain plants, particularly those like limes, lemons, grapefruit, celery, parsnip, parsley and more that contain photosensitising agents.

Recommendations for monitoring children's activities include supervising play involving plant exposure and ensuring protective measures, such as washing off plant residues and applying sunscreen, are taken. Awareness campaigns can further enhance understanding and safety practices, reducing the likelihood of similar reactions in the future.

The incidence of phytophotodermatitis raises significant public health concerns, particularly in regions with high sunlight exposure. A lack of awareness about plant-induced phototoxicity has led to preventable skin injuries in a number of cases. Preventive measures such as educational programs significantly reduce such incidents. This underscores the need for widespread public health campaigns and the incorporation of plant and sunlight safety into regular health advisories to better inform the public and safeguard community health.

This case study of phytophotodermatitis from exposure to lime juice and sunlight in Australia underscores the importance of awareness and preventive education in public health. The severe reactions experienced by children highlight the need for greater recognition and understanding of plant-induced phototoxic effects.

Moving forward, incorporating safety guidelines about photosensitising plants into public health advisories and educational programs is essential. By fostering awareness, we can protect vulnerable groups and prevent similar incidents, ensuring safer interactions with natural environments.