Introduction
Burn injuries can be encountered in all ages. The most common burn injuries among the Turkish population are caused by a variety of causes: fires, scalding substances (i.e., traditional Turkish tea, hot milk, etc.), electricity and chemical agents. When taking into account the mechanisms of chemical burns, it was observed that 4% of cases were caused by the application of herbs used as traditional medication [
1]. Despite the advances in medicine, a tendency towards using alternative treatments can be seen in every population, including the Turkish one, and plant application is among the most common methods used in folk medicine.
Ranunculus arvensis (a member of the
Ranunculaceae family) is a wild plant traditionally used in the Far East to treat arthritis, asthma, gout, high fever and psoriasis, and is highly allergenic in spring during the flowering period. In Turkey, the plant is frequently seen in the high mountains of the Mediterranean region and the southeastern and eastern regions of Anatolia, which are agricultural areas with plant production [
2‐
11]. Herein, we present three patients with chemical burns caused by
Ranunculus arvensis used as poultice around the knees and the thumb for the treatment of rheumatic symptoms.
Discussion
The plants of the genus
Ranunculus contain the toxic glycoside ranunculin. In case of dermal contact, ranunculin is broken down to protoanemonin, which leads to dermal-epidermal separation and formation of bullous lesions. This clinical condition is called phytodermatitis [
4,
8,
10].
Protoanemonin is a volatile and highly vesicant oil, whose toxicity may be explained by the increase in free oxygen radicals resulting in the inhibition of DNA polymerase. The irritant effect of protoanemonin is highest during spring when the plant is blooming and has fresh leaves, and decreases to a minimum as the plant dries up [
3]. All three patients reported in this study presented to our clinic in spring.
Members of the
Ranunculaceae family are widely used as traditional treatment in the form of poultices for various medical conditions, such as abscess drainage, bullous lesions, hemorrhoids, burns and lacerations, and in the form of herbal remedies for rheumatic and myalgic pain, common colds, etc. [
2,
8‐
10].
In the literature, the terms "plant burn" and "phytodermatitis" have been frequently used interchangeably. Metin et al. [
8] proposed the name 'phytodermatitis' to designate this medical condition; however, in our opinion, the important point is not the name, but how it is treated. After all, the above-mentioned two terms interpret alterations in the anatomic integrity of the skin with pathogenic mechanisms resembling those of burn injury. Therefore, treatment plans should be made in accordance with the methods for treating burns.
Eskitascioglu et al. [
4] noted in their study that the severity of chemical burns caused by plant poultices depends on the application method and duration. Reviewing the literature, we found that most patients used the plant as a poultice that was applied to the painful extremity and was covered with a cloth for a period ranging from 25 min to 48 h. We assume that this covering method increases the rate of contact and the degree of damage.
When scanning the literature using PubMed and the Google scholar database, we accessed ten articles on phytocontact dermatitis caused by plants from the
Ranunculaceae family. A total of 25 patients--18 females and 7 males--aged between 17 and 76 years (mean age: 53.4 ± 14.1 years) were presented in these studies. Twenty-one patients were living in the eastern and southeastern regions, and four in the western regions of Turkey. Age, gender and clinical data for the patients are summarized in Table
1. As shown in the table, women are two times more likely to use alternative medicine than men. Our experience supports this observation, and we postulate that it might be due to the fact that women are more prone to follow the advice of their neighbors and to trust folk medicine.
Table 1
Age, gender and clinical characteristics for 25 cases of phytocontact dermatitis caused by plants of the Ranunculaceae family and mimicking burn injuries (25 reported in the literature and our 3 cases)
2 | 64 | M | 12 h | Immediately | Left distal thigh |
R. arvensis
| Debridement, topical nitrofurantoin | 3 weeks |
3 | 17 | M | 48 h | 2 days | Back, scrotum, penis, chest |
R. arvensis
| Wet dressing, silver sulfadiazine, collogenase | 4 weeks |
4 | 42 | M | 8 h | 1 week | Left foot dorsum and ankle |
C. testiculatus
| Clorhexidine scrub + split thickness skin graft | 7 days |
| 40 | F | 4 h | 3 weeks | Right foot dorsum and ankle |
C. testiculatus
| Clorhexidine scrub + paraffin gauze | 10 days |
| 60 | F | 2 h | 10 days | Right foot dosrum and left knee |
C. testiculatus
| Clorhexidine scrub + paraffin gauze | 7 days |
| 65 | F | 2 h | 1 week | Left knee |
C. testiculatus
| Clorhexidine scrub+ paraffin gauze | 15 days |
| 48 | F | 4 h | 14 days | Right leg |
C. falcatus
| Clorhexidine scrub + paraffin gauze | 2 weeks |
5 | 52-76 | F:6 M:3 | 12 h | NA | Both knees: 7 One knee: 2 |
R. constantinopolitanus
| Topical antibacterial treatment | 10 d |
6 | 55 | F | 1 day | 2 days | Right knee | R. illyricus | Wet dressing and topical antibiotics | 4 days |
7 | 58 | F | 2 days | 5 days | Left knee |
R. illyricus
| Topical antibacterial cream | A few days |
| 54 | F | 1 days | 3 days | Right knee |
R. illyricus
| Wet dressing and topical antibiotic | 1 week |
8 | 69 | M | 2.5 h | 2 days | Left knee |
C. falcatus
| Wet dressing and topical fusidic acid | 2 weeks |
| 33 | F | 1.5 h | 2 days | Right distal leg, ankle, dorsal foot | C. falcatus | Wet dressing and topical antibiotic | 3 weeks |
| 18 | F | 1 h | 1 week | Left ankle, dorsal foot |
C. falcatus
| Wet dressing and topical antibiotic | 2 weeks |
9 | 47 | F | 25 min | NA | Right knee |
C. falcatus
| Wet dressing and topical mometasone cream | 10 days |
10 | 45 | F | Overnight | 2 days | Abdomen, right leg |
R. damascenus
| Wet dressing and topical fusidic acid | 10 days |
11 | NA | F | NA | NA | Right ankle |
C. falcatus
| Wet dressing | 2 weeks |
Current
| 48 | M | 1 h | 1 days | Right thumb |
R. arvensis
| Dressing with fusidic acid | 3 weeks |
| 59 | F | Overnight | 3 days | Bilateral knee |
R. arvensis
| Clorhexidine scrub + silver sulfadiazine cream | 2 weeks |
| 70 | F | 2 days | Immediately | Bilateral knee |
R. arvensis
| Clorhexidine scrub + silver sulfadiazine cream | 10 days |
In addition, the results of this literature scan revealed that people living in socio-culturally and economically underdeveloped regions are more enthusiastic about using alternative treatment methods. All of the patients presented in this study were living in a culturally backward area located in a mountainous and rural region of southeastern Turkey. As we have often observed, herbal products are frequently used for the purpose of treating psoriasis, hemorrhoids, back/lower back pain and arthralgia. This may be explained by the fact that folk medicine is an easily accessible, affordable and natural form of treatment; also, there is still a lack of reliance on pharmaceuticals as well as a desire to avoid long waiting times in the hospital.
Burn injuries are still a major cause of mortality and morbidity in most of the developing world, with burn wound infections being the most important complication. Loss of the normal skin barrier, as well as impairment of many systemic host-defense mechanisms, makes burn wounds susceptible to colonization and infection by multiple endogenous microorganisms. The patient remains vulnerable to invasive infection until the wound is completely epithelialized [
12]. Therefore, the areas with disrupted skin integrity should be covered as soon as possible, and, for this purpose, grafting and topical antibacterial dressing are most commonly used in the early stages. Reviewing the literature, we observed that in most of the reported cases, antimicrobial dressings were applied, and the predominantly used agents in burn wound care were: silver sulfadiazine, fusidic acid, mafenide, nitrofurazone, chlorhexidine, povidone-iodine, mupirocin, etc. In our burn unit, we frequently prefer dressings containing an antimicrobial agent to cover the burn wound.
In conclusion, although plant poultices applied to the skin show positive effects on many dermatological and rheumatic diseases, they also have many adverse effects. We believe that benefiting from modern medicine is the correct approach rather than attempting alternative treatment methods, whose therapeutic effects have not been proven yet by scientific studies.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AS, KO,CM and BM made the daily dressings; AS, YY, OA and SH contributed to writing the article and reviewing the literature as well as undertaking a comprehensive literature search; AS, BM, KO, SH and CM contributed to the design of the study and manuscript preparation.