BRIEF COMMUNICATION

Systemic photosensitivity due to Goji berries

Silvia G omez-Bernal, Laura Rodr guez-Pazos, Francisco Javier Garc a Mart nez, Manuel Ginarte, Mar a Teresa Rodr guez-Granados & Jaime Toribio
Department of Dermatology, Faculty of Medicine, Complejo Hospitalario Universitario, Santiago de Compostela, Spain

Summary
Key words:
Goji; herbal; Lycium barbarum; photosensitivity; phototesting

Correspondence:
Silvia G omez-Bernal, Departamento de Dermatolog a, Facultad de Medicina, C/San Francisco s/n. 15782 Santiago de Compostela, Spain. Tel:134 88 181 2245 Fax:134 98 152 8015 e-mail: sgomezbernal@gmail.com

Systemic photosensitivity due to the intake of plants or herbal compounds is a rare phenomenon. Goji berries are widely used as a well-being and anti-aging remedy. In spite of this, only a few adverse reactions and no cases of photosensitivity have been reported to date. A 53-year-old male consulted due to a pruriginous eruption located on sun-exposed areas of 2 weeks of duration. He had been taking Goji berries and infusions of cats claw herb for 5 and 3 months, respectively. Minimal erythema dose for UVB (MED-UVB) was diminished when the patient was taking these products, and became normal when they were withdrawn. Photoprovocation tests with Goji berries and cats claw were performed. MED-UVB decreased after the intake of Goji berries, and was normal with cats claw. We report the rst case of systemic photosensitivity due to Goji berries.

Accepted for publication:

23 May 2011

Conicts of interest:
None declared.

ystemic photosensitivity due to the intake of plants or herbal compounds is a rare phenomenon. Goji berries have become very popular over the last decade. They are sold as a well-being and anti-aging remedy (1). In spite of their widespread use, few adverse reactions and no cases of photosensitivity have been described to date. We report the rst case of systemic photosensitivity due to Goji berries. Case report A 53-year-old male with Fitzpatrick skin type III consulted in February 2010 Winter time in our country due to a pruriginous eruption located on sun-exposed areas of 2 weeks of duration, that appeared after a day out shing. He had started treatment with Vitreoclars (Angelini Farmac eutica, Barcelona, Spain) (glucosamine, hydrolyzed collagen, vitamin E, grape seed extract) 8 months before. He had also been taking one tablespoon of dried Goji berries every morning for the last 5 months and infusions of cats claw herb (every night and some mornings) for the last 3 months. He did not use topical or systemic drugs or sunscreens. He had no personal or family history of photosensitivity. Physical examination showed a diffuse erythema that affected the face and the neck (Fig. 1). The area under the chin and the back of the ears were spared (Fig. 2). Haemogram was normal and antinuclear antibodies were negative. Photobiological study was performed as follows. We

used a broadband UVB with 10 UVB-UV21 uorescent bulbs with an emission spectrum between 280 and 350 nm and a maximum at 306 nm (UV-800 Herbert Waldmann, Schwenningen, Germany), at a distance of 20 cm. Its total irradiance was 4.17 mW/cm2 and erythematous irradiance was 1.03 mW/cm2. UVB phototesting was performed by irradiating ve areas of uninvolved mid-lower back skin at increasing doses from 10 to 200 mJ/cm2. The source of emission of UVA was a bank of ve uorescent bulbs (PUVA 181 AL Herbert Waldmann) at an 11 cm distance (irradiance 10 mW/cm2) with an emission spectrum between 315 and 400 nm and a maximum at 356 nm. Phototest with UVA was done irradiating two areas in the upper part of the back with 6 and 10 J/cm2. The phototest was rst performed while the patient was taking Goji berries, cats claw and Vitreoclars. It showed a minimal erythematous dose for UVB (MED-UVB) of 50 mJ/cm2 and an abnormal response a pruriginous erythematoedematous plaque that persisted for 7 days in the area irradiated with 1.5 MED. Phototest with UVA was negative. As the composition of Vitreoclars was available and it did not have any known photosensitizer, we decided to withdraw Goji berries and cats claw and not to discontinue Vitreoclars. Four weeks later, UVB phototesting was repeated. At this time, the MED-UVB was 150 mJ/cm2. With the patients informed consent, photoprovocation tests with Goji berries and cats claw were performed while the patient was still taking Vitreoclars. Firstly, the patient took the Goji berries as he used to do for a week and a new
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G omez-Bernal et al.

Fig. 2. Lateral photograph showing that the retroauricular area and the areas covered by the clothes were spared.

Fig. 1. Frontal photograph showing the diffuse erythema that affected the face and the neck.

phototest was carried out. It showed a MED-UVB of 50 mJ/cm2. Months later, photoprovocation taking cats claw at the usual dosage for three weeks was done. This phototest showed a normal MED-UVB. Once Goji berries and cats claw were withdrawn the patient became asymptomatic and remained this way during a follow up period of 12 months. Discussion Systemic photosensitivity due to the intake of plants or herbal compounds is a rare adverse event. Hypericum perforarum is the most common cause (2). It has been reported to cause phototoxic reactions after topical application and systemic photosensitivity after ingestion (3). Celery and Ammi majus fruit have been associated with systemic photosensitivity too (2). Goji berries are the fruit of Lycium barbarum and Lycium chinese. These plants have long been used in Chinese traditional medicine and became popular in Europe and North America in recent years
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(1). Cats claw is the common name for Uncaria tomentosa and Uncaria guianensis, a plant from South America that has been used for centuries to treat several infectious and inammatory diseases (4). In spite of their long history of traditional use, there are scarce reports of adverse effects due to these plants. Up to date, only two cases of interaction with warfarin, and a few cases of urticaria-like (sic) or papular rashes due to Goji berries have been documented (1). Goji berries are not known to be photosensitizers. A recent study suggested that Goji juice may even provide photoprotection for humans as it was found to decrease the oedema induced by an acute sunburn in mice (5). In our patient, systemic photosensitivity due to Goji berries was demonstrated by the diminished MED-UVB while he was taking the berries and the cats claw, its normalization once they were withdrawn and the positive photoprovocation test with Goji berries. The absence of new episodes of the eruption in a 12-month follow-up period supports this diagnosis. Some authors have speculated that the combination of several herbal compounds could interact to cause adverse reactions. A photosensitivity reaction was observed in a woman who used a herbal supplement that contained 15 different ingredients (2). None of them was known to be phototoxic individually and the authors speculated that the combination of ingredients could have interacted to cause the reaction (2). Although cats claw

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photoprovocation was negative, we cannot exclude that it could be implicated in our patients photosensitivity. This plant inhibits the cytochrome P450 3A4 (CYP3A4) (4), which metabolizes several drugs and toxic compounds. Cats claw may have interacted with the components or the metabolites of Goji berries as well as with preservatives or contaminants that may have been present in them. The possibility of an interaction between the Goji berries and the Vitreoclars cannot be excluded. Probably few people use these products simultaneously. This would explain why no other cases of photosensitivity due to Goji berries have been reported in spite of its widespread use. In conclusion, we reported a case of systemic photosensitivity due to Goji berries conrmed by the photobiological study. To the best of our knowledge, no other cases have been reported previously. The simultaneous use of Goji berries and cats claw may have been important for this patients photosensitivity. We must be aware of new cases of photosensitivity reactions caused by dietary supplements as there has been a rapid increase in the use of these products in recent years (6).

References
1. Potterat O. Goji (Lycium barbarum and L. chinese): Phytochemistry, pharmacology and safety in the perspective of traditional uses and recent popularity. Planta Med 2010; 76: 719. 2. Palanisamy A, Haller C, Olson KR. Photosensitivity reaction in a woman using an herbal supplement containing ginseng, goldenseal and bee polen. J Toxicol Clin Toxicol 2003; 41: 865867. 3. Lane-Brown MM. Photosensitivity associated with herbal preparations of St Johns wort (Hypericum perforatum). Med J Aust 2000; 172: 302. 4. Valerio LG Jr, Gonzales GF. Toxicological aspects of the South American herbs cats claw (Uncaria tomentosa) and Maca (Lepidium meyenii): a critical synopsis. Toxicol Rev 2005; 24: 1135. 5. Reeve VE, Allanson M, Arun SJ, Domanski D, Painter N. Mice drinking goji berry juice (Lycium barbarum) are protected from UV radiatio-induced skin damage via antioxidant pathways. Photochem Photobiol Sci 2010; 9: 601607. 6. Temple NJ. The marketing of dietary supplements in North America: the emperor is (almost) naked. J Altern Complement Med 2010; 16: 803806.

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