Abstract
Marking nut or Bhilawa is the fruit of plant Semecarpus anacardium Linn (Family; Anacardiaceae). It belongs to Semecarpus genera which also includes cashew nuts. It is closely related to Rhus and Toxicodendron genera, which includes poison ivy and poison sumac and causes similar skin reaction due to the presence of compound urushiol. Marking nut dermatitis is an uncommon problem but has special importance in military dermatology. Individuals can get exposed to this plant during camping which can result in an irritant or allergic contact dermatitis. It can also be applied deliberately to cause factitious dermatitis. We present 5 cases of factitious dermatitis resulting from application of marking nut.
Keywords: Marking nut, Bhilawa, Semecarpus anacardium, Factitious dermatitis, Dermatitis artefacta
Introduction
Marking nut also known as Bhilawa or Semecarpus anacardium is the fruit of plant Semecarpus anacardium Linn. (Family: Anacardiaceae). It has a hard-black rind, which is its pericarp and contains pure black acrid juice. This plant is a native to India and is called marking nut because its resin was used by washerman to mark clothes. It has been classified as a poisonous medical plant in Drugs and Cosmetics act, India (1940). The active principles of the plant include anacardic acid and bhilawanol, other compounds are cardol, catechol, anacardoside, fixed oil, semecarpol, phenolic compounds and so on. Urushiol is present in other plants of Anacardiaceae family such as cashew nut, mango, poison ivy, poison oak, poison sumac and Japanese lacquer tree. Bhilawanol is a mixture of cis and trans isomer of urushiol.1 The fruit and nut extract of marking nut has antiatherogenic, anti-inflammatory, antioxidant, antimicrobial, anticarcinogenic and hypoglycemic properties. It is also used in Indian system of medicine in treating various diseases such as rheumatism, nervous debility, epilepsy, asthma and sciatica.2 The oleoresins present in marking nut can cause both irritant and allergic contact dermatitis. Owing to easy availability and knowledge about this plant in the Indian subcontinent, it can be used in causing dermatitis artefacta. We hereby present five cases of dermatitis artefacta in young males caused by marking nut.
Case 1
A 27-year-old male patient, presented with complaints of red raised itchy lesions of 15 days duration. There was no history of topical application or drug intake before the onset of the lesions. Dermatological examination showed involvement of the face, trunk and extremities in the form of urticarial plaques. Both cubital fossae were involved with erythematous plaques. There was no mucosal involvement. The patient was treated with 0.5 mg/kg/day of oral prednisolone and supportive treatment with differential diagnosis of atopic dermatitis and allergic contact dermatitis. After initial improvement, further aggravation was noted after one week in the form of linear erosions with black crusts over the trunk (Fig. 1). The aggravation of symptoms while in the hospital, linear erosions and his non-chalant attitude towards apparently severe disease led us to suspect dermatitis artefacta. Marking nuts were found in his belongings and on confronting, he confessed having applied it to create lesions (Fig. 2). He was diagnosed as marking nut dermatitis, counselled and treated with 10 mg of Tab cetirizine at night, 0.1% of mometasone cream once a day and emollients twice a day.
Fig. 1.
(a) Involvement of trunk with widespread urticarial eruption, linear erosions and black crusts. (b) Another case in which urticarial lesions have improved but black residue may be seen.
Fig. 2.
(a) Involvement of beard area of face with vesiculo-pustular eruption. (b) Marking nut or Semecarpus anacardium found in possession of the individual.
Case 2
A 24-year-old male patient, presented with complaints of red raised itchy lesions of 7 days duration. There was no history of topical application or drug intake. Dermatological examination showed involvement of trunk, back and upper extremities in the form of urticarial plaques with sparing of the mid-back (Fig. 3). Initial differential diagnosis of allergic contact dermatitis was kept; however, in view of our previous experience and sparing of difficult to reach areas over back, dermatitis artefacta was suspected. On direct questioning, patient confessed to having applied marking nut a day before the onset of symptoms. He was diagnosed as marking nut dermatitis and treated with anti-histaminic and topical steroid.
Fig. 3.
Involvement of back with urticarial eruption with sparing of central area.
Case 3 and 4 had involvement of scalp, face and trunk. They were initially diagnosed as seborrhoeic dermatitis. Case 5 presented with a vesiculo-pustular eruption apart from crusted erosions and was diagnosed as irritant contact dermatitis. Details of case 3, 4 and 5 have been tabulated in Table 1. None of the patients had any previous psychiatric illness. Case 1 and 3 had a previous history of similar illness. A written informed consent was taken from all patients.
Table 1.
Clinical features of patient with marking nut dermatitis.
| Sr .No | Age/sex | Involvement | Dermatological examination | Initial diagnosis |
|---|---|---|---|---|
| 1 | 27/male | Face, trunk and upper extremities | Urticarial plaques, bizarre crusted erosions with black crust | Atopic dermatitis Allergic contact dermatitis |
| 2 | 24/male | Face, trunk, back and upper extremities | Widespread urticarial plaque with sparing of mid-back | Irritant contact dermatitis |
| 3 | 28/male | Scalp, face, neck and upper extremities | Urticarial plaques over neck, scaly erythematous plaques over face and scalp | Seborrhoeic dermatitis Phyto-photodermatitis |
| 4 | 19/male | Scalp, face and upper extremities | Urticarial plaques over neck, scaly erythematous plaques in scalp and face | Seborrhoeic dermatitis Phyto-photodermatitis |
| 5 | 25/male | Scalp, face and trunk | Vesicles and pustules over face and neck, polysized crusted erosions with black coloured crust over trunk | Irritant contact dermatitis |
Discussion
Factitious disorders are self-inflicted skin lesions and involves creation of skin lesions with mechanical injury (pressure, trauma, friction, occlusion, biting, cutting, thermal burns) or chemicals (acid, alkali, irritants) toxic to skin. The current classification consists of four groups: (a) Dermatitis artefacta syndrome is unconscious or dissociated self-injury; (b) Dermatitis par-artefacta syndrome is manipulation of an existing specific dermatosis, often semiconscious and comes under impulse control disorder; (c) Malingering is consciously simulated injury for secondary material gains; (d) other special forms such as Munchausen syndrome or Munchausen syndrome by proxy. While the term dermatitis artefacta is used broadly for many of these diseases, it should be used when the following criteria are fulfilled: intentional production of skin lesions, motivation is to assume sick role and absence of external incentives such as an economic gain. As discussed earlier, when the disease is simulated for secondary gain, it is termed malingering. It is difficult to differentiate these two entities as it is difficult to establish secondary gain when the patient denies causing the lesions in first place.3,4
Marking nut juice can result in both irritant and allergic contact dermatitis. The typical eruption manifests as erythema, oedema, papules, vesicles or bullae. The linear streaks are characteristic but may not be seen in all cases. The black colour on erosions is evidence of resin residue. The irritant reaction develops within hours while the allergic contact dermatitis develops in presensitised individuals in hours to days. Diagnosis is based on high index of suspicion, clinical examination and a thorough history taking. Histopathology is non-specific and may show subcorneal cleft, necrotic keratinocyte and spongiosis. Patch testing can be performed with diluted constituents to confirm the allergic nature of the reaction.5 In our series of 5 cases, facial involvement was seen in all the cases and scalp involvement in 3 cases. Urticarial plaques were predominant morphology in 4 cases and vesiculo-pustular eruption in one case; erosions with black crusts were present in 2 cases.
This juice is applied for pain relief, warding off the evil eye and in the Indian system of medicine for various other purposes.6,7 Poor handling of the nut while administering self-treatment usually results in the dermatitis. The accidental leakage of the content of shipment from India also resulted in an irritant skin reaction in 16 individuals working in the mail department of Washington as far back as in 1943.8 The marking nut dermatitis also has important consideration in military medicine. Before World war II, soldiers developed dermatitis when the clothes were laundered and marked with marking nut, hence the name “Dhobi-mark dermatitis” or dhobi-itch.9 In World war II, soldiers developed dermatitis on exposure to marking nut tree. Individuals who get sensitised to Bhilawanol can also develop rashes with other plants of Anacardiaceae family such as cashew nut, mango and poison ivy. This cross-reactivity occurs due to urushiol present in these plants. It is important for a soldier going to jungles to identify and avoid these plants.10 The black residue is present on lesions caused by these plants, and the same findings can be replicated by crushing sap carefully on a sheet of white paper. This stain becomes darker on exposure to air and helps in identify plants of Toxicodendron genera. This test is known as the black spot test and is a crude test to identify Toxicodendron and related genera such as Semecarpus.11 The juice can also be applied deliberately on the skin to create skin rashes for secondary gains such as avoidance of duty. The diagnosis can be made by suspecting patients presenting with sudden onset illness, bizarre skin lesions, poor corroborative history of evolution and non-chalant attitude of the patient. Confrontation may help in finding out causative agent, method of application and motive in these individuals. Facial involvement and linear erosions with black crusts may act as an indicator for the diagnosis.
Conclusion
Marking nut dermatitis is an important cause of skin rash in military medicine. Patients should be made aware of the poisonous nature of these plants. Deliberate use of these agents for secondary gain should be suspected in individuals with relevant history and motive.
Disclosure of competing interest
The authors have none to declare.
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