A rare chemical burn due to Ranunculus arvensis: three case reports

Abstract

Ranunculus arvensis, a plant that is a member of Ranunculaceae family, generally used for local treatment of joint pain, muscle pain, burns, lacerations, edema, abscess drainage, hemorrhoids, and warts among the population. In this case report, we presented three patients who developed chemical skin burns after using R arvensis plant locally for knee pain. The destructive effect of the plant has been reported previously to be more in fresh plants and less in dried plants. Although protoanemonin, which is considered as the main toxic substance, was reported to be absent in dried or boiled plants, the plant was boiled, cooled, and wrapped over the region with pain in our cases. Therefore, we thought that protoanemonin may be considered to be heat resistant. Also, the burn management proceeded up to surgery by using the flap technique in one of our patients in contrast to the cases found in published reports who were treated by antibiotics and dressings.

Full text

case report
Ann SAudi Med 2016 JAnuARY-FeBRuARY www.AnnSAudiMed.net 89
Ranunculus arvensis, a member of the
Ranunculaceae family, grows spontaneously in
environments at altitudes between 1 and 1850
m, as an element of the vegetation.1 In Turkey, this plant
grows particularly in the Mediterranean, Eastern, and
Southeastern Anatolia regions. It is generally used for
the treatment of joint pain, muscle pain, burns, lac-
erations, edema, abscess drainage, hemorrhoids, and
warts among the population.2 However, this plant may
cause skin inammation and injury of mucous mem-
branes as side effects. The destructive effect of the
A rare chemical burn due to Ranunculus
arvensis: three case reports
Abdullah O. Kocak, Murat Saritemur, Kenan Atac, Sibel Guclu, Ibrahim Ozlu
From the Department of Emergency Medicine, Faculty of Medicine, Ataturk University, Erzurum, Turkey
Correspondence: Dr. Abdullah Osman Kocak · Department of Emergency Medicine, Faculty of Medicine, Ataturk University, Erzurum
25700, Turkey · T: (+90)-0442-344-8390 · abdullahmrym86@gmail.com
Ann Saudi Med 2016; 36(1): 89-91
DOI: 10.5144/0256-4947.2016.89
Ranunculus arvensis, a plant that is a member of Ranunculaceae family, generally used for local treat-
ment of joint pain, muscle pain, burns, lacerations, edema, abscess drainage, hemorrhoids, and warts
among the population. In this case report, we presented three patients who developed chemical skin
burns after using R arvensis plant locally for knee pain. The destructive effect of the plant has been re-
ported previously to be more in fresh plants and less in dried plants. Although protoanemonin, which
is considered as the main toxic substance, was reported to be absent in dried or boiled plants, the
plant was boiled, cooled, and wrapped over the region with pain in our cases. Therefore, we thought
that protoanemonin may be considered to be heat resistant. Also, the burn management proceeded
up to surgery by using the flap technique in one of our patients in contrast to the cases found in pub-
lished reports who were treated by antibiotics and dressings.
plant has been reported to be more in fresh plants and
less in dried plants.1
In this case report, 3 patients who used R arvensis
plant locally for pain after boiling, and who developed
chemical skin burns thereafter are presented.
CASE 1
A 51-year-old female patient was admitted to the
Emergency Department, Ataturk University, Erzurum,
Turkey, with swelling and redness on her right leg. Her
medical history revealed that she had boiled the ower
Figure 1. (a) Second-degree burn was present on her right leg; (b) ap treatment was used.

case report cheMicAl BuRnS
ANN SAUDI MED 2016 JANUARY-FEBRUARY WWW.ANNSAUDIMED.NET
90
named “wedding bloom” among the population and
wrapped it around her knee for knee pain. After 12
hours, when she opened the wrap, she noticed red-
Figure 2. Plant used also conrmed as Ranunculi arvensis.
Figure 3. Swelling and redness developed after 5 hours.
Figure 4. Chemical burn 10 hours after wrap was opened.
ness and swelling on her leg. Her vital signs during ad-
mission were within normal limits and second-degree
burn was present on her right leg (Figure 1a). She was
hospitalized in the burn unit of the hospital. During
follow-up, since epithelization of the burn area was in-
sufcient, ap treatment was used (Figure 1b). On her
16th day of admission, 80% healing was observed and
she was discharged from the hospital. The plant that
she used was photographed and was also conrmed as
R arvensis (Figure 2) by the patient herself.
CASE 2
A 52-year-old female patient had boiled the same ow-
er while it was fresh and applied it to her left knee for a
period of 5 hours for her complaint of knee pain. After
5 hours, swelling and redness developed in her leg
(Figure 3). Physical examination revealed a skin burn
of 10×10 cm2 in size, extending from the knee region
down to her foot. The patient, whose vital signs were
within normal limits, was admitted to the burn unit of
the hospital. She was treated by changing her dressings
daily. After 5 days, when her complaints regressed, she
was discharged.
CASE 3
A 57-year-old female patient was admitted with com-
plaints of pain, redness, and swelling on her right leg.
She stated that she had boiled and then wrapped
around her knee the ower known as a medicinal
herb among the population. Ten hours later, when she
opened the wrap, and the appearance was like the pic-
ture shown in Figure 4. She was diagnosed with chemi-
cal burn and was admitted to the burn unit of the hos-
pital. She was followed up by changing her dressings
daily, and when signicant improvement was observed
in the burn area, she was discharged from the hospital
on her seventh day of admission.
DISCUSSION
Plants have been used since ancient times for medicinal
purposes, and many side effects related to these plants
have been reported.3 R arvensis is known as “wedding
bloom” in Turkey. When the plant is fresh, all of its parts
are considered as poisonous, and its destructive effect
is enhanced. The severity of these effects is related to
the size of the contact area, duration of contact, and
amount of the plant used. The injury is generally mani-
fested as chemical burn, with its development mecha-
nism being related to irritancy, phototoxicity, and hy-
persensitivity reactions.4 Ranunculus species contain
ranunculin. The ranunculin contained in ranunculus
species is normally 10 mg/g of dry weight. Ranunculin

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ANN SAUDI MED 2016 JANUARY-FEBRUARY WWW.ANNSAUDIMED.NET 91
1. Orak M, Ustundag M, Guloglu C, Tas M,
Baylan B. A skin burn associated with Ra-
nunculus arvensis (wedding bloom). Indian
J Dermatol. 2009; 54(5):19–20.
2. Ucmak D, Ayhan E, Meltem Akkurt Z,
Haydar U. Presentation of three cases with
phyto contact dermatitis caused by Ra-
nunculus and Anthemis genera. J Derma-
tol Treat. 2014 Dec; 25(6):467–9. PubMed
PMID: 24188033.
3. Sayhan MB, Gokdemir MT, Guloglu C,
Orak M, Ustundag M. A burn case associ-
ated with Ranunculus arvensis. Anatol J Clin
Investig. 2009; 3:85–7.
4. Albayrak Y, Albayrak A, Melikoglu M,
Kordali S. Chemical burn caused by Ranun-
culus arvensis. Wounds. 2011; 23(3):E6–8.
5. Sedivy C, Piskorski R, Muller A, Dorn S.
Too low to kill: concentration of the sec-
ondary metabolite ranunculin in buttercup
pollen does not affect bee larval survival.
J Chem Ecol. 2012 Aug; 38(8):996–1002.
PubMed PMID: 22711029.
6. Akbulut S, Semur H, Kose O, Ozhasenekler
A, Celiktas M, Basbug M, et al. Phytocontact
dermatitis due to Ranunculus arvensis mim-
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literature review. Int J Emergen Med. 2011;
4:7. PubMed PMID: 21408003. Pubmed
Central PMCID: 3051894.
is the precursor of protoanemonin, which is a toxic sub-
stance and the actual toxic effect is considered to be
caused by protoanemonin.5 Protoanemonin is a volatile
and highly irritant oil, which increases the free oxygen
radicals through inhibition of deoxyribonucleic acid
polymerase.3 It contains extremely irritant lipids, such as
saponins, hederagenin, and oleanolic acid glucosides,
within its structure.1,3
When applied on the skin surface, R arvensis
leads to bullae formation together with sub-epithelial
detachment, through destruction of sulfur chains.
Protoanemonin, which is considered as the main toxic
substance, was reported to be absent in dried or boiled
plants.1 In 7 cases reported earlier, the plant was di-
rectly applied to the skin without any boiling process
and then the skin was covered.1-4,6 However, in the cas-
es discussed here, the plant was boiled, cooled, and
wrapped over the region with pain. This situation is the
rst of its kind in the published reports.
In conclusion, the claim that the dried or boiled form
of the R arvensis plant is void of toxic protoanemonin
is not true. Protoanemonin as it seems is heat-resistant
and may lead to extensive chemical burn that may even
require a skin ap.
Acknowledgments
We would like to acknowledge Emergency Department
staff of Ataturk University Medical Faculty.
REFERENCES