Phytophotodermatitis Explained

Phytophotodermatitis
Synonyms:berloque dermatitis, margarita photodermatitis, lime disease, lime phytodermatitis
Causes:photosensitizer and UV-A light
Differential:skin burn
allergic contact dermatitis

Phytophotodermatitis, also known as berloque dermatitis,[1] [2] [3] margarita photodermatitis,[4] [5] lime disease[6] or lime phytodermatitis[6] is a cutaneous phototoxic inflammatory reaction resulting from contact with a light-sensitizing botanical agent (such as lime juice) followed by exposure to ultraviolet A (UV-A) light (from the sun, for instance). Symptoms include erythema, edema, blisters (vesicles and/or bullae), and delayed hyperpigmentation. Heat and moisture tend to exacerbate the reaction.

A reaction may be elicited in any person who has been exposed to adequate amounts of both a photosensitizer and UV-A light. Phytophotodermatitis is not an immunologic response; no prior exposure to the photosensitizing agent is required.

The photosensitizing substances found in phototoxic plants belong to a class of chemical compounds called the furanocoumarins, which are activated by long-wavelength ultraviolet (UV-A) light. The most toxic of these organic compounds are the linear furanocoumarins, so called since they exhibit a linear chemical structure. Bergapten and xanthotoxin (also known as methoxsalen), two linear furanocoumarins derived from psoralen, are invariably found in plants associated with phytophotodermatitis.

Symptoms and signs

A reaction typically begins within 24 hours of exposure and peaks at 48–72 hours after exposure.[7] Initially, the skin turns red and starts to itch and burn. Large blisters (or bullae) form within 48 hours.[8] The blisters may leave black, brown, or purplish scars that can last for several years. This hyperpigmentation of the skin is caused by the production of melanin triggered by the furanocoumarins.

Although media reports have suggested that eye exposure to the agent can lead to temporary or permanent blindness, the risk of permanent blindness is not supported by existing research.[9]

Phytophotodermatitis can affect people of any age. In children, it has sometimes been mistaken for child abuse.[10]

Phototoxic species

Plants associated with phytophotodermatitis mainly come from four plant families:[11] the carrot family (Apiaceae), the citrus family (Rutaceae), the mulberry family (Moraceae), and the legume family (Fabaceae).

Apiaceae

The carrot family Apiaceae (or Umbelliferae) is the main family of plants associated with phytophotodermatitis. Of all the plant species that have been reported to induce phytophotodermatitis, approximately half belong to the family Apiaceae.[12]

False bishop's weed (Ammi majus), the world's major source of the linear furanocoumarin xanthotoxin, has been used since antiquity to treat vitiligo but accidental or inappropriate use of this plant can lead to phytophotodermatitis.[13] Despite this danger, A. majus continues to be cultivated for its furanocoumarins,[14] which are still used for the treatment of skin disease.

Numerous species in the family Apiaceae are cultivated as food products, some of which exhibit phototoxic effects. In particular, celery, parsnip, and parsley have been reported to cause phytophotodermatitis among agricultural workers, grocery workers, and other occupational food handlers.[15] [16] [17] [18] [19] [20]

A number of phototoxic plant species in the carrot family have become invasive species, including wild parsnip (Pastinaca sativa)[21] [22] and the tall hogweeds of the genus Heracleum,[23] [24] namely, Persian hogweed (Heracleum persicum), Sosnowsky's hogweed (Heracleum sosnowskyi), and giant hogweed (Heracleum mantegazzianum). In particular, the public health risks of giant hogweed are well known.[25]

Other plant species in the family Apiaceae that are associated with phytophotodermatitis include blister bush (Notobubon galbanum), cow parsley (Anthriscus sylvestris), wild carrot (Daucus carota), various species of the genus Angelica (e.g., Korean angelica Angelica gigas), and most (if not all) species of the genus Heracleum (esp. the tall invasive hogweeds and the cow parsnips, Heracleum sphondylium and Heracleum maximum).

Rutaceae

The citrus family Rutaceae is the second most widely distributed family of plants associated with phytophotodermatitis.

Numerous citrus fruits in the family Rutaceae exhibit phototoxic effects. Of these, perhaps the best known is lime.[26] [27] [28] Phytophotodermatitis associated with limes is sometimes colloquially referred to as "lime disease,"[29] [30] not to be confused with Lyme disease.

In the family Rutaceae, the most severe reactions are caused by the essential oil of the bergamot orange (Citrus bergamia).[31] Bergamot essential oil has a higher concentration of bergapten (3000–3600 mg/kg) than any other citrus-based essential oil, even lime oil, which contains 1700–3300 mg/kg of bergapten.[32]

Other plant species in the family Rutaceae that are associated with phytophotodermatitis include burning bush (Dictamnus albus),[33] common rue (Ruta graveolens),[34] [35] [36] [37] and other plants in the genus Ruta.

Moraceae

The mulberry family Moraceae is often associated with phytophotodermatitis. Multiple species in the genus Ficus are known to exhibit phototoxic effects. Of these, the common fig (Ficus carica) is well known and thoroughly documented.

Like Ammi majus in the family Apiaceae, the common fig has been used since antiquity to treat vitiligo but the milky sap of fig leaves can cause phytophotodermatitis if used accidentally or inappropriately.[38] [39] [40] [41] [42] [43] A literature search revealed 19 cases of fig leaf-induced phytophotodermatitis reported between 1984 and 2012. In Brazil, several hospitals reported more than 50 cases of fig leaf-induced burn in one summer. In most cases, patients reportedly used the leaves of the fig plant for folk remedies, tanning, or gardening.

Other plant species in the family Moraceae that are associated with phytophotodermatitis include Ficus pumila[44] [45] and Brosimum gaudichaudii.[46] Like Ficus carica, the South American species Brosimum gaudichaudii has been shown to contain both psoralen and bergapten.

Prevention

The first and best line of defense against phytophotodermatitis is to avoid contact with phototoxic substances in the first place:

A second line of defense is to avoid sunlight, so as not to activate a phototoxic substance:

Phytophotodermatitis is triggered by long wavelength ultraviolet light (called UVA) in the range of 320–380 nanometers, so the best sun-protective clothing and sunscreen products will block these wavelengths of UVA radiation.

In 2011, the U.S. Food and Drug Administration (FDA) established a "broad spectrum" test for determining a sunscreen product's UVA protection.[49] Sunscreen products that pass the test are allowed to be labeled as "Broad Spectrum" sunscreens, which protect against both UVA and UVB rays.

There is no equivalent test or FDA-approved labeling for sun-protective clothing. Some clothing is labeled with an Ultraviolet Protection Factor (UPF) but test results from Consumer Reports[50] suggest that UPF is an unreliable indicator of UV protection.

Treatment

Many different topical and oral medications may be used to treat the inflammatory reaction of phytophotodermatitis. A dermatologist may also prescribe a whitening cream to help treat the hyperpigmentation and return the skin pigmentation back to normal. If the patient does not receive treatment, the affected sites may develop permanent hyperpigmentation or hypopigmentation.

History

The photosensitizing effects of plants have been known since antiquity. In Egypt around 2000 B.C., the juice of Ammi majus "was rubbed on patches of vitiligo after which patients were encouraged to lie in the sun." In A.D. 50, the Greek physician Dioscorides observed that pigment would return to patches of vitiligo if "cataplasmed with the leaves or the boughes of the Black Figge,"[51] an apparent reference to Ficus carica, the common fig. These ancient practices acknowledged the hyperpigmentation effects now known to accompany phytophotodermatitis.

One of the earliest reports of plant-based dermatitis was given by Chaumton in 1815, who noted that the outer rind and root of cow parsnip (a common name for any Heracleum species of plant) contained an acrid sap sufficiently strong to inflame and ulcerate the skin.[52] Similarly in 1887 Sornevin reported that Heracleum sphondylium caused dermatitis. However, neither of these early reports recognized the crucial role of ultraviolet radiation.

"Berloque dermatitis" (from the French word "berloque" meaning trinket or charm) is a term coined by Rosenthal in 1925 to describe the pendant-like streaks of pigmentation observed on the neck, face, and arms of patients.[53] He was unaware that, in 1916, Freund had correctly observed that these pigmentation effects were due to sun exposure after the use of Eau de Cologne, a perfume infused with bergamot oil.[54] It is now known that bergamot oil contains a significant amount of bergapten, a linear furanocoumarin that gets its name from the bergamot orange.

In 1937, dermatitis from Heracleum mantegazzianum was reported by Miescher and Burckhardt who suspected the possibility of light sensitization.[55] A few years later, Kuske confirmed this hypothesis.[56] [57] In 1942, Klaber introduced the term "phytophotodermatitis" to emphasize that both plants and light were required to affect a reaction.[58] [59]

Darrell Wilkinson, a British dermatologist, gave an accurate description of the clinical entity in the 1950s.[60] [61] In 1961, Efremov reported 357 cases of phytophotodermatitis from Heracleum dulce (sweet cow parsnip). He "noted the requirement for sunlight in evoking the dermatitis since inunction of the juice of the plant without exposure to sunlight was harmless."[62] Between 1962 and 1976, numerous reports of phytophotodermatitis from giant hogweed (Heracleum mantegazzianum) were reported. By 1980, the photosensitizing effects of various plant species had become well known (as evidenced by the comprehensive work of Mitchell and Rook[63]).

See also

Notes and References

  1. Book: William Daniel . James . Timothy G. . Berger . Dirk M. . Elston . Andrews' Diseases of the Skin: Clinical Dermatology . Saunders Elsevier . 2006 . 32 . 978-0-7216-2921-6 .
  2. The Electronic Textbook of Dermatology . Botanical Dermatology . McGovern . Thomas W. . Barkley . Theodore M. . Section Phytophotodermatitis . Internet Dermatology Society . 2000 . 37 . 5 . 10.1046/j.1365-4362.1998.00385.x . 9620476 . 221810453 . November 29, 2018 .
  3. Web site: Berloque Dermatitis . Alikhan . Ali . March 4, 2016 . Medscape . August 9, 2018 .,
  4. What Caused The Rash On This Man's Wrist And Hand? . Ryan R. . Riahi . Philip R. . Cohen . Floyd W. . Robinson . James M. . Gray . June 2009 . The Dermatologist . 11 . 6 .
  5. Abramowitz . Alan I. . Resnik . Kenneth S. . Cohen . Kenneth R. . Margarita photodermatitis . The New England Journal of Medicine . 328 . 12 . 891 . March 1993 . 8441448 . 10.1056/NEJM199303253281220 . free .,
  6. Lakshmi Nagireddi . Rachel Raimondo . Robert Hostoffer Jr . January 24, 2022 . Recurrent Bilateral Lime Disease in a Young Female- Case Report . Lime phytodermatitis, also known as margarita dermatitis, is a condition that results in a skin rash after sunlight exposure when handling certain plants. Misdiagnosis is common due to its resemblance to skin burns or allergic contact dermatitis. Detailed history and disease recognition is important to provide accurate treatment recommendations. . Allergy and Rhinology (Providence) . 13 . 10.1177/21526567221074944 . 35096464 . 8796115 . 21526567221074944 .
  7. Web site: Phytophotodermatitis . Baugh . William P . September 8, 2016 . Medscape . August 9, 2018 .
  8. Solis . R. R. . Dotson . D. A. . Trizna . Z. . Phytophotodermatitis: a sometimes difficult diagnosis . Archives of Family Medicine . 9 . 10 . 1195–6 . 2000 . 11115230 . 10.1001/archfami.9.10.1195 .
  9. Web site: Giant Hogweed . Ministry of Natural Resources and Forestry, Government of Ontario . Peterborough, Ont. . July 15, 2018 . 2.
  10. Barradell . R. . Addo . A. . McDonagh . A. J. G. . Cork . M. J. . Wales . J. K. H. . Phytophotodermatitis mimicking child abuse . European Journal of Pediatrics . 152 . 4 . 291–2 . April 1993 . 8482273 . 10.1007/BF01956735 . 11778627 .
  11. Kavli . G. . Volden . G. . Phytophotodermatitis . Photo-Dermatology . 1 . 2 . 65–75 . April 1984 . 6397734 .
  12. Pathak . M. A. . Daniels Jr. . Farrington . Fitzpatrick . T. B. . The Presently Known Distribution of Furocoumarins (Psoralens) in Plants . Journal of Investigative Dermatology . September 1962 . 39 . 3 . 225–239 . 10.1038/jid.1962.106 . 13941836 . free .
  13. Alouani . I. . Fihmi . N. . Zizi . N. . Dikhaye . S. . Phytophotodermatitis following the use of Ammi Majus Linn (Bishop's weed) for vitiligo . Our Dermatol. Online . 2018 . 9 . 1 . 93–94 . 10.7241/ourd.20181.29 . free .
  14. Web site: Plants For A Future: Ammi majus.
  15. Birmingham . D. J. . Key . M. M. . Tublich . G. E. . Perone . V. B. . Phototoxic bullae among celery harvesters . Arch Dermatol . 1961 . 83 . 1 . 73–87 . 10.1001/archderm.1961.01580070079008 . Cited in McGovern and Barkley 2000, section Phytophotodermatitis.
  16. Centers for Disease Control (CDC) . Phytophotodermatitis among grocery workers--Ohio . MMWR. Morbidity and Mortality Weekly Report . 34 . 1 . 11–3 . January 1985 . 3155560 .
  17. Berkley . S. F. . Hightower . A. W. . Beier . R. C. . Fleming . D. W. . Brokopp . C. D. . Ivie . G. W. . Broome . C. V. . Dermatitis in grocery workers associated with high natural concentrations of furanocoumarins in celery . Annals of Internal Medicine . 105 . 3 . 351–5 . September 1986 . 2943201 . 10.7326/0003-4819-105-3-351.
  18. Aberer . W. . Occupational dermatitis from organically grown parsnip (Pastinaca sativa L.) . Contact Dermatitis . 26 . 1 . 62 . January 1992 . 1534739 . 10.1111/j.1600-0536.1992.tb00880.x . 31255626 .
  19. Book: Lovell . C. R. . Plants and the skin . 1993 . Blackwell Scientific Publications . Oxford . 1st . Cited in McGovern and Barkley 2000, section Phytophotodermatitis.
  20. Lutchman . L. . Inyang . V. . Hodgkinson . D. . Phytophotodermatitis associated with parsnip picking . Journal of Accident & Emergency Medicine . 16 . 6 . 453–4 . November 1999 . 10572825 . 1343418 . 10.1136/emj.16.6.453 .
  21. Wild parsnip (Pastinaca sativa): A troublesome species of increasing concern . Averill . Kristine M. . Di'Tommaso . Antonio . Weed Technology . 2007 . 21 . 279–287 . 10.1614/WT-05-186.1 . 86774319 .
  22. Cain . N. . Darbyshire . S. J. . Francis . A. . Nurse . R. E. . Simard . M.-J. . The Biology of Canadian weeds. 144. Pastinaca sativa L. . Can. J. Plant Sci. . 2010 . 90 . 2 . 217–240 . 10.4141/CJPS09110 .
  23. Book: 87-7903-209-5 . The giant hogweed best practice manual: guidelines for the management and control of invasive weeds in Europe . Booy . O. . Cock . M. . Eckstein . L. . Hansen . S. O. . Hattendorf . J. . Hüls . J. . Jahodová . S. . Krinke . L. . Marovoková . L. . Müllerová . J. . Nentwig . W. . Nielsen . C. . Otte . A. . Pergl . J. . Perglová . I. . Priekule . I. . Pusek . P. . Ravn . H. P. . Thiele . J. . Trybush . S. . Wittenberg . R. . 2005 . Hørsholm: Center for Skov, Landskab og Planlægning/Københavns Universitet . September 1, 2018 .
  24. Web site: Giant Hogweed (Heracleum mantegazzianum): Best Management Practices in Ontario . MacDonald . F. . Anderson . H. . May 2012 . Ontario Invasive Plant Council, Peterborough, ON . September 1, 2018 .
  25. Web site: Health Hazards & Safety Instructions for Giant Hogweed (with graphic photos) . New York State Department of Environmental Conservation . September 3, 2018.
  26. Gross . T. P. . Ratner . L. . de Rodriguez . O. . Farrel . K. P. . Israel . E. . An outbreak of phototoxic dermatitis due to limes . American Journal of Epidemiology . 125 . 3 . 509–14 . March 1987 . 3812457 . 10.1093/oxfordjournals.aje.a114557.
  27. Kung . A. C. . Stephens . M. B. . Darling . T. . Phytophotodermatitis: bulla formation and hyperpigmentation during spring break . Military Medicine . 174 . 6 . 657–61 . June 2009 . 19585784 . 10.7205/milmed-d-01-7208. free .
  28. Hankinson . Andrew . Lloyd . Benjamin . Alweis . Richard . Lime-induced phytophotodermatitis . Journal of Community Hospital Internal Medicine Perspectives . 4 . 4 . 25090 . 2014 . 25317269 . 4185147 . 10.3402/jchimp.v4.25090 .
  29. Web site: Lime Disease: How a Fruity Drink Can Give You a Rash . July 24, 2017 . SciShow . November 5, 2018.
  30. Weber . Ian C. . Davis . Charles P. . Greeson . David M. . Phytophotodermatitis: the other "lime" disease . The Journal of Emergency Medicine . 17 . 2 . 235–7 . 1999 . 10195477 . 10.1016/S0736-4679(98)00159-0 .
  31. Kaddu . S. . Kerl . H. . Wolf . P. . Accidental bullous phototoxic reactions to bergamot aromatherapy oil . J Am Acad Dermatol . 2001 . 45 . 3 . 458–461 . 10.1067/mjd.2001.116226 . 11511848 . Cited in CIR 2013.
  32. Web site: The German Research Foundation (DFG) . Toxicological Assessment of Furocoumarins in Foodstuffs . DFG Senate Commission on Food Safety (SKLM) . 2004 . November 1, 2018.
  33. Schempp . C. M. . Sonntag . M. . Schöpf . E. . Simon . J. C. . Dermatitis bullosa striata pratensis caused by Dictamnus albus L. (burning bush) . Hautarzt . September 1996 . 47 . 9 . 708–710 . 8999028 . German . 10.1007/s001050050494. 23601334 .
  34. Wessner . D. . Hofmann . H. . Ring . J. . Phytophotodermatitis due to Ruta graveolens applied as protection against evil spells . Contact Dermatitis . 41 . 4 . 232 . October 1999 . 10515113 . 10.1111/j.1600-0536.1999.tb06145.x . 45280728 .
  35. Furniss . Dominic . Adams . Titus . Herb of grace: an unusual cause of phytophotodermatitis mimicking burn injury . Journal of Burn Care & Research . 28 . 5 . 767–9 . 2007 . 17667834 . 10.1097/BCR.0B013E318148CB82 .
  36. Eickhorst . Kimberly . Deleo . Vincent . Csaposs . Joan . Rue the herb: Ruta graveolens--associated phytophototoxicity . Dermatitis . 18 . 1 . 52–5 . March 2007 . 17303046 . 10.2310/6620.2007.06033 .
  37. Arias-Santiago . S. A. . Fernández-Pugnaire . M. A. . Almazán-Fernández . F. M. . Serrano-Falcón . C. . Serrano-Ortega . S. . Phytophotodermatitis due to Ruta graveolens prescribed for fibromyalgia . Rheumatology . 48 . 11 . 1401 . November 2009 . 19671699 . 10.1093/rheumatology/kep234 . free .
  38. Bollero . D. . Stella . M. . Rivolin . A. . Cassano . P. . Risso . D. . Vanzetti . M. . Fig leaf tanning lotion and sun-related burns: case reports . Burns . November 2001 . 27 . 7 . 777–779 . 10.1016/S0305-4179(01)00033-X . 11600261 .
  39. Derraik . J. G. . Rademaker . M. . Phytophotodermatitis caused by contact with a fig tree (Ficus carica) . N Z Med J . 2007 . 120 . 1261 . U2720 . 17867224 .
  40. Polat . Muhterem . Öztaş . Pınar . Dikilitaş . Meltem Cik . Allı . Nuran . Phytophotodermatitis due to Ficus carica . Dermatol Online J . December 2008 . 14 . 12 . 9 . 10.5070/D3046507Z8 . 19265622 .
  41. Zhang . Ruzhi . Zhu . Wenyuan . Phytophotodermatitis due to Chinese herbal medicine decoction . Indian J Dermatol . 2011 . 56 . 3 . 329–331 . 10.4103/0019-5154.82498 . 21772602 . 3132918 . free .
  42. Sforza . Marcos . Andjelkov . Katarina . Zaccheddu . Renato . Severe burn on 81% of body surface after sun tanning . Turkish Journal of Trauma and Emergency Surgery . July 2013 . 19 . 4 . 383–384 . 10.5505/tjtes.2013.44522 . 23884685 . free .
  43. Son . J. H. . Jin . H. . You . H. S. . Shim . W. H. . Kim . J. M. . Kim . G. W. . Kim . H. S. . Ko . H. C. . Kim . M. B. . Kim . B. S. . Five Cases of Phytophotodermatitis Caused by Fig Leaves and Relevant Literature Review . Annals of Dermatology . 29 . 1 . 86–90 . February 2017 . 28223753 . 5318534 . 10.5021/ad.2017.29.1.86 .
  44. English . P. B. . Grey . L. P. . Sap dermatitis and conjunctivitis caused by the wild fig (Ficus pumila) . Medical Journal of Australia . June 1943 . 1 . 26 . 578–579 . 10.5694/j.1326-5377.1943.tb44690.x . Cited in Mitchell and Rook 1979.
  45. Rademaker . M. . Derraik . J. G. . Phytophotodermatitis caused by Ficus pumila . Contact Dermatitis . July 2012 . 67 . 1 . 53–56 . 10.1111/j.1600-0536.2012.02026.x . 22681467 . 39421000 .
  46. Martins . José Eduardo Costa . Pozetti . Gilberto L. . Sodré . Mariana . Effects of psoralen and bergapten on irradiated skin . Int J Dermatol . 1974 . 13 . 3 . 124–128 . 10.1111/j.1365-4362.1974.tb01781.x . 4836605 . 33210327 .
  47. Web site: Sun-related Skin Condition Triggered by Chemicals in Certain Plants, Fruits . Davis . Dawn . August 12, 2011 . Dermatology, Mayo Clinic . August 8, 2018 .
  48. Web site: Phytophotodermatitis: When plants and light affect the skin . Leonard . Jayne . August 19, 2017 . Medical News Today . August 8, 2018 .
  49. Web site: FDA announces new requirements for over-the-counter (OTC) sunscreen products marketed in the U.S. . June 11, 2011 . U.S. Food and Drug Administration . August 9, 2018.
  50. Web site: Testing sun protective clothing . August 11, 2015 . Consumer Reports . August 9, 2018.
  51. Book: Mitchell . John . Rook . Arthur . Botanical Dermatology: Plants and Plant Products Injurious to the Skin . 1979 . Greengrass . Vancouver . 978-0-88978-047-7. Cited in McGovern and Barkley 2000, section Phytophotodermatitis.
  52. Chaumton, FP (1815). Flore Med Paris. 2: 32. Cited by Mitchell and Rook (1979), p. 692.
  53. Rosenthal . O. . Berloque dermatitis: Berliner Dermatologische . Dermatologische Zeitschrift . 1925 . 42 . 295 . 10.1159/000250611. Cited in Alikhan 2016.
  54. Freund . E. . Uber bisher noch nicht beschriebene kunstliche Hautverfarbungen . Dermatol Wochenschrift . 1916 . 63 . 931–933 . Cited in McGovern and Barkley 2000, section Phytophotodermatitis.
  55. Miescher . G. . Burckhardt . W. . Herakleum Dermatitis: Case Presentation . Schweizer Medizinische Wochenschriff . 1937 . 67 . 82 . Cited by Mitchell and Rook (1979), p. 696.
  56. Kuske . H. . Experimental investigations on photodermatitis caused by plant juices . Archiv für Dermatologie und Syphilis . 178 . 273 . Cited by Mitchell and Rook (1979), p. 696.
  57. Kuske . H. . Perkutane Photosensibilisierung durch pflanzliche Wirkstoffe. Dermatology. 82 . 5–6 . 273 . 10.1159/000253838. 1940 . Cited by Mitchell and Rook (1979), p. 696.
  58. Klaber . R. . Phytophotodermatitis . Br. J. Dermatol. . 1942 . 54 . 7 . 193–211 . 10.1111/j.1365-2133.1942.tb10682.x. 209143689 . Cited by McGovern and Barkley, section Phytophotodermatitis.
  59. de Almeida Junior . Hiram Larangeira . Sartori . Débora Sarzi . Jorge . Valéria Magalhães . Rocha . Nara Moreira . de Castro . Luis Antonio Suita . Phytophotodermatitis: A Review of Its Clinical and Pathogenic Aspects . Journal of Dermatological Research . 2016 . 1 . 3 . 51–56 . 10.17554/j.issn.2413-8223.2016.01.15. free .
  60. Web site: Munks Roll Details for Peter Edward Darrell Sheldon Wilkinson . munksroll.rcplondon.ac.uk . 2017-11-10.
  61. Web site: 2013-05-30 . Munks Roll Details for Peter Edward Darrell Sheldon Wilkinson . 2024-06-08 . https://web.archive.org/web/20130530063155/http://munksroll.rcplondon.ac.uk/Biography/Details/6188 . 2013-05-30 .
  62. Efremov . A. I. . The Photodermatitis caused by Sweet Cow Parsnip (Heracleum dulce) . Vestn. Derm. Vener. . Russian . 4 . 64 . Cited by Mitchell and Rook (1979), p. 693.
  63. Book: Mitchell . John . Rook . Arthur . Botanical Dermatology: Plants and Plant Products Injurious to the Skin . 1979 . Greengrass . Vancouver . 978-0-88978-047-7 .

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