A Case of Irritant Contact Dermatitis Associated with Pulsatilla koreana.

Dear Editor:

A 52-year-old female patient was referred to our clinic with widespread bullae on both feet (Fig. 1A, B). One day before her visit, she had applied a mix of the ground stem, leaves, and roots of Pulsatilla koreana to her feet as she had heard that Pulsatilla was effective against plantar fasciitis, which she had been suffering from for the last 4 months. The patient reported feeling a burning sensation and pain 2 hours after applying the Pulsatilla, and 2 hours later, she was unable to tolerate the symptoms. She then removed the ground Pulsatilla and found multiple erythematous bullae on her feet. There was no history of application of other topical agents. She was diagnosed with irritant contact dermatitis (ICD) from topical application of P. koreana, which belongs to the Ranunculaceae family. The patient was treated with a systemic steroid, antibiotics, and antihistamines; further, daily dressings with topical steroid and antibiotics were applied. Her lesions resolved after 2 weeks, and some hyperpigmentation remained (Fig. 1C, D). We received the patient's consent form about publishing all photographic materials.

Fig. 1

(A, B) Multiple and huge bullae accompanied by burning sensation on both feet. (C, D) The lesions were improving without recurrence but left hyperpigmentation on both feet. (E) Picture of Pulsatilla koreana. Modified from “Pulsatilla koreana NAKAI [Internet]”, by Rural Development Administration, 2006, Jeonju: Rural Development Administration; [cited 2018 Nov 1]. Available from: http://www.rda.go.kr/ptoPtoMainSearchFocusList.do?searchKey=title&searchVal=%ED%95%A0%EB%AF%B8%EA%B D%83. Copyright 2006 by the Rural Development Administration. Reprinted with permission.

ICD triggered by plants is common and differs from allergic contact dermatitis in that it can occur in anyone exposed to an irritant1. P. koreana is a member of the genus Pulsatilla, which belongs to the Ranunculaceae family2, that has been used in folk remedies as an anti-inflammatory, analgesic, and astringent agent in Korea3. The plants of Ranunculaceae family are known to contain protoanemonin, a blister-causing compound. When protoanemonin reacts with sulfhydryl groups, it disrupts the disulfide bonds in the skin, destroying the subepidermal junction and creating blisters1. Protoanemonin is particularly abundant in the leaves and stems of Pulsatilla plants and is released when the leaves and stems are crushed. This compound causes irritant reactions even if it is applied to the skin for a short time4. Continuous exposure may cause erythema, edema, blistering, and hyperpigmentation.

Thus far, four cases of ICD due to P. koreana have been reported in Korea (Table 1)23. ICD cases associated with other Ranunculaceae species have also been reported14. The common features of ICD caused by the plants of Ranunculaceae family are the rapid appearance of the symptoms after exposure to the skin, protoanemonin-induced blisters, and prolonged hyperpigmentation. In this case, the lesions were limited to the contact area and occurred immediately after contact, and the clinical course was consistent with the preexisting reports, which enabling the diagnosis of ICD associated with P. koreana.

Table 1

Summary of clinical informations of 4 cases reported as irritant reactions by Pulsatilla koreana

Author	Sex/age (yr)	Purposes and site	Times to develop symptom	Clinical presentation and symptom	Treatment
Kim et al.3	Female/20	Left facial nerve palsy	Immediately	Wide bullae upon erythematous patch with burning sensation	Not mentioned
Song et al.2	Female/67	Anti-wrinkle effects on face	20 minutes	Bullae with burning sensation	Antiseptic cream
	Female/57	Both knee pain due to rheumatic arthritis	2 hours	Burning sensation	Antiseptic cream
	Female/68	Right wrist pain due to rheumatic arthritis	1 hour	Burning sensation	Antiseptic cream
		Whitening effects on face
Present case	Female/52	Plantar fasciitis	2 hours	Wide bullae on both feet with burning and itching sensation	Systemic steroid, antibiotics, antihistamines
					Daily dressing with topical steroid, antibiotics

Despite the advancements in modern medicine, many cases with systemic problems, in addition to cutaneous problems, still occur due to unproven folk remedies. We have experienced a case of ICD associated with the topical application of P. koreana based on a folk remedy. We report this case to highlight that physicians' treatments are evidence-based and have been proven effective and safe by many clinical studies conducted in a large number of patients. In addition, we aim to discourage the general public from resorting to indiscreet folk remedies with a review of the literature.