VIGNETTE IN CONTACT DERMATOLOGY

Occupational contact dermatitis to hydrangea

Marius Rademaker

Dermatology Department, Waikato Hospital, Hamilton, New Zealand

SUMMARY

Two female commercial hydrangea growers, from separate nurseries, presented with similar hand and facial dermatitis. Bothhad a hand dermatitis affecting particularly the first three fingers and backs of both hands and complained of a recurrentfacial dermatitis affecting the forehead, around both the eyes and bridge of nose. They related their dermatitis to their work.Patch tests confirmed allergy to all components of hydrangeas including petal, leaf and stem. Avoidance resulted in resolutionof their dermatoses. Allergy to hydrangeas has been reported previously although infrequently.

Key words: allergic contact dermatitis,

Hydrangea macrophylla

, phytodermatitis.

INTRODUCTION

Phytodermatitis is well recognized in Australia and NewZealand. With increasing ease of international transport,new plant cultivars are beginning to be grown commerciallyin Australasia. Two cases of occupationally acquired phyto-dermatitis from hydrangea are reported.

Case 1

A 35-year-old commercial hydrangea grower presented witha 2-year history of a hand dermatitis. This affected initiallythe tips of the thumb, index and middle fingers but thenspread to affect all of the fingers and the backs of both hands.Over time the rash spread to involve the forehead and cheeksof the face. She had worked as a commercial hydrangeagrower for 7 years, initially as a picker and then as a packer.The rashes would clear in the off-season and when she wenton holiday. In New Zealand, hydrangeas are planted in Juneand July (winter) and harvested in December to April(summer). Gloves did not seem to help greatly. No pesticidesor fungicides were used. She was patch tested using IQchambers (Chemotechnique Diagnostics, Malmo, Sweden)with readings at 48 and 96 hours, using the InternationalContact Dermatitis Research Group (ICDRG) criteria. Shehad a modified standard series applied (ChemotechniqueDiagnostics) as well as specific series of agricultural pesti-cides (Trolab, Reinbeck, Germany), plants and woods, andtars and balsams. Components of her hydrangeas (stem,

flower/petals, and leaf) were tested as is (1 cm

2

slithers ofplant), as well as the petals prepared in water and olive oil(minced petals vigorously shaken in water or olive oil for5 min, the liquid then applied onto an IQ chamber).

She had a 1+ reaction at 48 hours and 2+ reaction at96 hours to the petal (as is, in water, and in olive oil), leaf andstem of her hydrangea. In addition she had an equivocalreaction

to

thiram

(48

and

96 hours), and a 1+ reactionto manganese ethylene bis-dithiocarbamate (Maneb) at96 hours (equivocal at 48 hours).

Treatment included hand care, polyvinyl gloves, severalpotent and super-potent topical corticosteroids, and topicalhand PUVA (photochemotherapy). This resulted in onlymodest improvement. It was only when she avoided allcontact with hydrangea (by switching to office work) that herdermatitis settled.

Case 2

A 48-year-old commercial hydrangea grower presented witha 12-month history of a dermatitis affecting her fingers andbacks of hands. In addition she had a recurrent dermatitis ofthe face (forehead, around the eyes and nose). She had beena commercial hydrangea grower for 3 years, previouslyhaving grown orchids commercially for 6 years. No pesti-cides were used although they occasionally used an organicmixture of garlic and paraffin oil. The hydrangeas weregrown for the cut-flower trade.

The rash would appear within 1–2 days of contact withhydrangeas. She had no problems in the off-season. She waspatch tested as the previous case, with a 1+ reaction at48 hours and 2+ reaction at 96 hours to leaf, inner stem andouter stem. She also had a 1+ reaction to nickel (48 and96 hours), an equivocal reaction to ethylenediamine (signifi-cance unclear) and a 1+ reaction to colophony (historicalreaction to Elastoplast).

Correspondence: Assoc. Prof. Marius Rademaker, DermatologyDepartment, Waikato Hospital, Hamilton, New Zealand. Email: rademaker@xtra.co.nz.

Marius Rademaker, FRACP.Manuscripts for this section should be submitted to Assoc. Prof.

M Rademaker.Submitted 5 February 2003; accepted 27 March 2003.

Australasian Journal of Dermatology (2003) 44, 220–221

DISCUSSION

Hydrangea (Hydrangea macrophylla, Hortensia) is a lush,deciduous and evergreen shrub native to China, Japan andNorth America. It is one of 17 genera of the family Hydrange-aceae (with 23 species). They have striking dome-shapedflowers. Each head consists of small flowers surrounded bylarger petal-like sepals. In soils with a pH of up to 5.5, blueor purple flowers bloom, above this pH level they are oftenpink. White flowers are unaffected by soil pH.

Allergy to hydrangea appears uncommon but is recog-nized.1–7 A series of eight cases of allergic contact dermatitisfrom hydrangea were seen in Angers, France, over a 15-yearperiod.7 Angers provides almost 90% of hydrangea seedlingproduction in France. The dermatitis was occupationallyacquired, being found only among nursery workers. Patchtests with the stem as well as the hydrangea leaf gave strongpositive reactions in all patients. The allergen appears to behydrangenol (3,4-dihydro-8-hydroxy-3-(4-hydroxyphenyl)-isocoumalin). Isolated in 1930, it was demonstrated to be astrong contact sensitizer using the guinea pig maximizationtest.5 Five of the eight patients from Angers had strongpositive reactions to patch testing to 0.1% hydrangenol inpetrolatum. Hydrangenol is found in the leaves, stem andpetals of most cultivars of hydrangeas. Other constituents ofhydrangea, including umbelliferone, kaempferol, hydrangeaacid, phyllodulcin and lunularic acid, do not appear to be aproblem.7 Sensitization seems to have occurred after closeand prolonged contact with the plant.

These eight patients, like the two patients in the currentcase, presented with a hand dermatitis, affecting particularlythe first three fingers, reminiscent of ‘tulip fingers’ found inDutch nursery workers. This may reflect the handling tech-nique of long-stemmed flowers. Cut hydrangeas often havestems 75–100 cm long, the hand holding the stem (thumb,index and middle fingers) slides down the shaft of the stemto where it is then cut. The face can easily brush against theflower head, resulting in the facial dermatitis seen in bothpatients.

Occupational dermatitis to decorative flowers has beenreported in the literature but few include reactions tohydrangea. Twelve cases were described of occupationalallergic contact dermatitis caused by Compositae (fivepatients; chrysanthemum, elecampane, gerbera, feverfew),

Alstroemeniaceae (five patients; alstroemeria), Liliaceae(four patients; tulip, hyacinth), Amaryllidaceae (two patients;narcissus) and Caryophyllaceae (two patients; carnation,cauzeflower).8 A Dutch group reported 14 patients withallergic reactions from handling flowers.9 Symptoms variedfrom allergic rhinoconjunctivitis and asthma to urticaria.The responsible plants did not include hydrangea. InAustralasia the largest series of plant dermatitis has beenreported from the Contact Dermatitis Clinic, Skin and CancerFoundation (Darlinghurst, NSW, Australia).10 They reported68 patients with positive patch tests to 88 plants, mostlyGrevillea species, Compositae, Rhus and Alstroemeria.

With increasing ease of international transport and trade,new plants are being grown commercially in Australasia. Asdermatologists, we need to be aware of these possible newcauses of phytodermatitis, which can be acquired bothoccupationally in commercial growers and in the homegarden.

REFERENCES

1. Bruynzeel DP. Allergic contact dermatitis to hydrangea. ContactDermatitis 1986; 14: 128.

2. Bruynzeel DP, Hausen BM. Allergic contact dermatitis tohydrangea. Contact Dermatitis 1987; 16: 181.

3. Meijer P, Coenraads PJ, Hausen BM. Allergic contact dermatitisfrom hydrangea. Contact Dermatitis 1990; 23: 59–60.

4. Bruynzeel DP. Contact dermatitis from hydrangea. ContactDermatitis 1991; 24: 78.

5. Hausen BM. Hydrangenol, a strong contact sensitizer found inhydrangea (Hydrangea sp., Hydrangeaceae). Contact Dermatitis1991; 24: 233–5.

6. Kuligowski ME, Chang A, Leemreize JH. Allergic contact handdermatitis from hydrangea: Report of a 10th case. ContactDermatitis 1992; 26: 269–70.

7. Avenel-Audran M, Hausen BM, le Sellin J, Ledieu G, Verret JL.Allergic contact dermatitis from hydrangea – is it so rare?Contact Dermatitis 2000; 43: 189–91.

8. Lamminpaa. A, Estlander T, Tolanki R, Kanerva L. Occupationalallergic contact dermatitis caused by decorative plants. ContactDermatitis 1996; 34: 330–5.

9. de Jong MV, Vermeulen AK, Gerth van Wijk R, de Groot H.Occupational allergy caused by flowers. Allergy 1998; 53:204–9.

10. Cook DK, Freeman S. Allergic contact dermatitis to plants. Ananalysis of 68 patients tested at the Skin and Cancer Foundation.Australas. J. Dermatol. 1997; 8: 129–31.

Book Reviews

Skin Pathology, 2nd edn. By David Weedon. ChurchillLivingstone, London, 2002. 1172 pages, including index.Price: A$684.75. ISBN 0443070695.

The first impression of this second edition of David Weedon’stext on dermatopathology relates to the sheer size of thebook. It has over 200 additional pages and is a larger

format than the first edition and is consequently consider-ably heavier. This has led to comments that it is not abook to be lifted from a shelf but rather to be left open on thebench to refer to at will. It is also not a book easily taken tobed to read last thing at night. Once again Weedon hascompleted this monumental text single-handedly, apartfrom the chapter on cutaneous lymphoma by Geoffrey

Hydrangea contact dermatitis 221