The kiss of (cell) death: can venom-induced immune response contribute to dermal necrosis following arthropod envenomations?

Introduction: Snakes, insects, arachnids and myriapods have been linked to necrosis following envenomation. However, the pathways involved in arthropod venom-induced necrosis remain a highly controversial topic among toxinologists, clinicians and the public. On the one hand, clinicians report on alleged envenomations based on symptoms and the victims' information. On the other hand, toxinologists and zoologists argue that symptoms are incompatible with the known venom activity of target species. This review draws from the literature on arthropod envenomations, snakebite, and inflammatory processes to suggest that envenomation by a range of organisms might trigger an intense inflammatory cascade that ultimately lead to necrosis. If confirmed, these processes would have important implications for the treatment of venom-induced necrosis. Objectives: To describe two inflammatory pathways of regulated necrosis, tumour necrosis factor (necroptosis) and Neutrophil Extracellular Traps (NETosis); to discuss existing knowledge about snake venom and arachnid-induced necrosis demonstrating the involvement of tumour necrosis factor and neutrophils in the development of tissue necrosis following envenomation and to contribute to the understanding of venom-induced necrosis by arthropods and provide clinicians with an insight into little known inflammatory processes which may occur post envenomation. Methods: ISI Web of Science databases were searched using the terms "spider bite necrosis", "arthropod envenomation necrosis", "venom necrosis", "venom immune response", "loxoscelism", "arachnidism", "necroptosis venom", "necroptosis dermatitis", "tumour necrosis factor TNF venom", "scorpionism", "scolopendrism", "centipede necrosis", "NETosis venom", "NETosis necrosis". Searches produced 1737 non-duplicate citations of which 74 were considered relevant to this manuscript. Non-peer-reviewed sources or absence of voucher material identifying the organism were excluded. What is necrosis? Necrosis is the breakdown of cell membrane integrity followed by inflowing extracellular fluid, organelle swelling and the release of proteolytic enzymes into the cytosol. Necrosis was historically considered an unregulated process; however, recent studies demonstrate that necrosis can also be a programmed event resulting from a controlled immune response (necroptosis). Tumour necrosis factor and the necroptosis pathway: Tumour necrosis factor is a pro-inflammatory cytokine involved in regulating immune response, inflammation and cell death/survival. The pro-inflammatory cytokine TNF-α participates in the development of necrosis after envenomation by vipers. Treatment with TNF-α-antibodies may significantly reduce the manifestation of necrosis. Neutrophil Extracellular Traps and the NETosis pathway: The process by which neutrophils discharge a mesh of DNA strands in the extracellular matrix to entangle ("trap") pathogens, preventing them from disseminating. Neutrophil Extracellular Traps have been recently described as important in venom-induced necrosis. Trapped venom accumulates at the bite site, resulting in significant localized necrosis. Arthropod venom driving necrosis: Insects, myriapods and arachnids can induce necrosis following envenomation. So far, the processes involved have only been investigated in two arachnids: Loxosceles spp. (recluse spiders) and Hemiscorpius lepturus (scorpion). Loxosceles venom contains phospholipases D which hydrolyse sphingomyelin, resulting in lysis of muscle fibers. Subsequently liberated ceramides act as intermediaries that regulate TNF-α and recruit neutrophils. Experiments show that immune-deficient mice injected with Loxosceles venom experience less venom-induced inflammatory response and survive longer than control mice. Necrosis following Hemiscorpius lepturus stings correlates with elevated concentrations of TNF-α. These observations suggest that necrosis may be indirectly triggered or worsened by pathways of regulated necrosis in addition to necrotic venom compounds. Conclusions: Envenomation often induce an intense inflammatory cascade, which under certain circumstances may produce necrotic lesions independently from direct venom activity. This could explain the inconsistent and circumstantial occurrence of necrosis following envenomation by a range of organisms. Future research should focus on identifying pathways to regulated necrosis following envenomation and determining more efficient ways to manage inflammation. We suggest that clinicians should consider the victim's immune response as an integral part of the envenomation syndrome.

Aspergilosis pulmonar invasiva en paciente anciano con absceso cerebral de origen odontogénico / Invasive pulmonary aspergillosis in an elderly patient with a cerebral abscess of odontogenic origin

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An outbreak of skin infections in neonates due to a Staphylococcus aureus strain producing the exfoliative toxin A.

PURPOSE: Staphylococcus aureus is an important cause of infections in hospitalized neonates. Preterm or low birthweight infants are especially at risk to develop a S. aureus infection due to the immaturity of the immune system, length of hospital stay and invasive procedures. Exfoliative toxin (ET)-producing S. aureus is often responsible for neonatal infections, causing clinical manifestations such as staphylococcal scalded skin syndrome, characterized by both localized blisters or generalized exfoliation of the skin. METHODS: We describe an outbreak due to an S. aureus strain producing ETA occurring in a local hospital in Northern Italy. Molecular typing of the isolates included spa typing and multilocus sequence typing. DNA microarray hybridization was also performed on one representative strain. RESULTS: In the period from July 2013 to February 2014, 12 neonates presented with skin infections, mainly bullae or pustules. Cultures of skin swabs yielded methicillin-susceptible S. aureus (MSSA). By molecular typing, an epidemic strain (t1393/ST5) was identified in nine neonates; microarray analysis and PCR revealed that it contained the ETA encoding gene. Screening of staff, mothers and healthy neonates and environmental cultures did not reveal the presence of the epidemic strain. However, the father of an infected neonate was found to be a carrier of MSSA t1393 five months after the outbreak started. CONCLUSION: Implementation of hygiene procedures and sanitization of the ward twice terminated the outbreak. Timely surveillance of infections, supported by molecular typing, is fundamental to prevent similar episodes among neonates.

Two highly divergent lineages of exfoliative toxin B-encoding plasmids revealed in impetigo strains of Staphylococcus aureus.

Exfoliative toxin B (ETB) encoded by some large plasmids plays a crucial role in epidermolytic diseases caused by Staphylococcus aureus. We have found as yet unknown types of etb gene-positive plasmids isolated from a set of impetigo strains implicated in outbreaks of pemphigus neonatorum in Czech maternity hospitals. Plasmids from the strains of clonal complex CC121 were related to archetypal plasmid pETBTY4. Sharing a 33-kb core sequence including virulence genes for ETB, EDIN C, and lantibiotics, they were assigned to a stand-alone lineage, named pETBTY4-based plasmids. Differing from each other in the content of variable DNA regions, they formed four sequence types. In addition to them, a novel unique plasmid pETB608 isolated from a strain of ST130 was described. Carrying conjugative cluster genes, as well as new variants of etb and edinA genes, pETB608 could be regarded as a source of a new lineage of ETB plasmids. We have designed a helpful detection assay, which facilitates the precise identification of the all described types of ETB plasmids.

Dermatoprotective effects of some plant extracts (genus Ficus) against experimentally induced toxicological insults in rabbits.

AIM: Present study was conducted to evaluate the dermatoprotective effects of plant extracts (Ficus religiosa, Ficus benghalensis, and Ficus racemosa) against known irritants such as sodium dodecyl sulfate (SDS), atrazine, and petrol. METHODS: The study was conducted in adult male rabbits. Ethanol extracts of plants were obtained through Soxhlet. All irritants and Ficus extracts were topically applied to the backs of rabbits daily for 4 days, while pure ethanol served as control. Skin was examined after 24, 48, and 96 h for erythema. Skin biopsies were taken on 5th day for microscopic examination. RESULTS: Erythema produced by irritants reduced significantly with the simultaneous application of Ficus extracts. The mean ± SEM epidermal thickness (micrometer) with SDS was 45.40 ± 1.89, F. religiosa + SDS was 18.60 ± 0.51, F. benghalensis + SDS was 18.40 ± 0.25, F. racemosa + SDS was 18.80 ± 0.37, and mixture of three Ficus species + SDS was 16.80 ± 0.37. Similar findings were revealed after using plant extracts with atrazine and petrol. The mean ± SEM epidermal layer count for SDS was 3.60 ± 0.25, atrazine was 3.40 ± 0.25, petrol was 3.40 ± 0.25, and ethanol (control) was 1.00 ± 0.20. This count reduced to 1.20 ± 0.20 for three Ficus species + SDS, 1.40 ± 0.25 for Ficus species + atrazine, and 1.40 ± 0.25 for Ficus species + petrol. CONCLUSION: Ficus species demonstrated the potential to block the dermatotoxic effects of topical irritants and could be used successfully to prevent skin toxicity.

Spatial and thematic distribution of research on cyanotoxins.

Cyanobacteria in surface water are well known for their ability to form toxic blooms responsible for animal mortality and human poisoning. Accompanying major progress in science and technology, the state of knowledge of cyanotoxins has dramatically increased over the last two decades. The bibliometric approach applied in this study shows the evolution of research and identifies major gaps to be filled by future work. Although the publication rate has gradually increased from one hundred to three hundred articles per year since the 1990s, half of the literature available focuses on microcystins and another quarter on saxitoxins. Other cyanotoxins such as beta-N-methylamino-l-alanine or cylindrospermopsin remain vastly disregarded. Moreover, most of the publications deal with toxicity and ecology while other research areas, such as environmental and public health, require additional investigation. The analysis of the literature highlights the main journals for the communication of knowledge on cyanotoxins but also reveals that 90% of the research is originated from only ten countries. These countries are also those with the highest H-index and average number of citation per article. Nonetheless, the ranking of these countries is significantly altered when the amount of publications is normalized based on the population, the number of universities, the national gross domestic product or the government revenue. However, the lower amount of publications from Eastern Europe, Africa and South America could also reflect the lack of monitoring campaigns in these regions. This lack could potentially lead to the underestimation of the prevalence of toxic cyanobacterial blooms and the diversity of toxins worldwide.

Xenobiotic metabolism capacities of human skin in comparison with a 3D epidermis model and keratinocyte-based cell culture as in vitro alternatives for chemical testing: activating enzymes (Phase I).

Skin is important for the absorption and metabolism of exposed chemicals such as cosmetics or pharmaceuticals. The Seventh Amendment to the EU Cosmetics Directive prohibits the use of animals for cosmetic testing for certain endpoints, such as genotoxicity; therefore, there is an urgent need to understand the xenobiotic metabolizing capacities of human skin and to compare these activities with reconstructed 3D skin models developed to replace animal testing. We have measured Phase I enzyme activities of cytochrome P450 (CYP) and cyclooxygenase (COX) in ex vivo human skin, the 3D skin model EpiDerm™ (EPI-200), immortalized keratinocyte-based cell lines and primary normal human epidermal keratinocytes. Our data demonstrate that basal CYP enzyme activities are very low in whole human skin and EPI-200 as well as keratinocytes. In addition, activities in monolayer cells differed from organotypic tissues after induction. COX activity was similar in skin, EPI-200 and NHEK cells, but was significantly lower in immortalized keratinocytes. Hence, the 3D model EPI-200 might represent a more suitable model for dermatotoxicological studies. Altogether, these data help to better understand skin metabolism and expand the knowledge of in vitro alternatives used for dermatotoxicity testing.

Xenobiotic metabolism capacities of human skin in comparison with a 3D-epidermis model and keratinocyte-based cell culture as in vitro alternatives for chemical testing: phase II enzymes.

The 7th Amendment to the EU Cosmetics Directive prohibits the use of animals in cosmetic testing for certain endpoints, such as genotoxicity. Therefore, skin in vitro models have to replace chemical testing in vivo. However, the metabolic competence neither of human skin nor of alternative in vitro models has so far been fully characterized, although skin is the first-pass organ for accidentally or purposely (cosmetics and pharmaceuticals) applied chemicals. Thus, there is an urgent need to understand the xenobiotic-metabolizing capacities of human skin and to compare these activities to models developed to replace animal testing. We have measured the activity of the phase II enzymes glutathione S-transferase, UDP-glucuronosyltransferase and N-acetyltransferase in ex vivo human skin, the 3D epidermal model EpiDerm 200 (EPI-200), immortalized keratinocyte-based cell lines (HaCaT and NCTC 2544) and primary normal human epidermal keratinocytes. We show that all three phase II enzymes are present and highly active in skin as compared to phase I. Human skin, therefore, represents a more detoxifying than activating organ. This work systematically compares the activities of three important phase II enzymes in four different in vitro models directly to human skin. We conclude from our studies that 3D epidermal models, like the EPI-200 employed here, are superior over monolayer cultures in mimicking human skin xenobiotic metabolism and thus better suited for dermatotoxicity testing.

Staphylococcus sciuri exfoliative toxin C (ExhC) is a necrosis-inducer for mammalian cells.

Staphylococcus sciuri (S. sciuri) is a rare pathogen in humans, but it can cause a wide array of human infections. Recently a S. sciuri isolate (HBXX06) was reported to cause fatal exudative epidermitis (EE) in piglets and thus considered as a potential zoonotic agent. To investigate the pathogenicity of this bacterium, we cloned exfoliative toxin C (ExhC), a major toxin of the S. sciuri isolate and performed functional analysis of the recombinant ExhC-his (rExhC) protein using in vitro cell cultures and newborn mice as models. We found that rExhC could induce necrosis in multiple cell lines and peritoneal macrophages as well as skin lesions in newborn mice, and that the rExhC-induced necrosis in cells or skin lesions in newborn mice could be completely abolished if amino acids 79-128 of rExhC were deleted or blocked with a monoclonal antibody (3E4), indicating aa 79-128 portion as an essential necrosis-inducing domain. This information contributes to further understandings of the mechanisms underlying S. sciuri infection.

Molecular studies of an impetigo bullosa epidemic in full-term infants.

BACKGROUND: Carriers of Staphylococcus aureus strains can be the source of epidemic infection for patients. OBJECTIVES: A molecular epidemiological analysis of an impetigo bullosa outbreak in a neonatal ward was performed in order to determine a potential source of the infection and possible routes of subsequent spreading of the epidemic strain. METHODS: The genetic relatedness of S. aureus strains isolated from 6 neonates with epidermal lesions and from 21 staff members was verified by the pulsed field gel electrophoresis (PFGE) method. Additionally, detection of eta and etb genes of S. aureus strains using PCR was performed. RESULTS: None of the infected newborns' mothers was a carrier. Seven strains, 6 isolated from the newborns and 1 taken from a midwife, showed the same restriction pattern, i.e. type A. In the other 20 health care workers colonized with S. aureus, 3 genetic types could be distinguished, i.e. B (2), C (7) and D (2), as well as 9 strains with unique PFGE patterns. The eta gene detected in 7 strains belonged to the genetic type A; there was no etb gene in any of the 27 S. aureus isolates. CONCLUSIONS: The presence of the same genetic type A of S. aureus in the infected newborns is a factor which indicates that the impetigo bullosa was a hospital infection. A probable source of the infection was a midwife who was colonized with the same S. aureus type. She was present at the birth of the first infected newborn. Today, molecular methods are essential for prompt recognition of an epidemic and implementation of appropriate infection control strategies.

An outbreak of Paederus dermatitis in a primary school, Terengganu, Malaysia.

Outbreaks of Paederus dermatitis have been reported in several Asia-Pacific countries when rove beetles (genus Paederus) are accidentally brushed or crushed on the skin, releasing haemolymph pederin. An investigation was conducted in a school to ascertain the causative agent, establish the case definition, epidemiological characterisation of cases, entomological and environmental survey and data analysis. This outbreak occurred among 36 schoolchildren attending a night tuition class conducted by their teacher. Dermatitis developed within 24 hours in 33/37 (89.2%) cases with itchiness as the first presenting symptom in 87.9% of cases. Periorbital oedema and erythematous-vesicular plaques on the upper extremities were seen in 57.6% of cases, on the back (36.4%) and on the nape (24.2%). Signs and symptoms were present 12 hours after exposure in 66.7% of cases with burning sensation within four hours in 9.1%. Seven cases received out-patient treatment. Thirty cases (90.9%) recalled exposure to Paederus fuscipes with 28 (84.8%) cases admitting crushing or brushing the insects. (Relative risk = 2.2; 95% CI: 1.2; 4.2). The school with fluorescent lighting, was located next to paddy fields. P. fuscipes was easily found in the paddy fields and along the school corridors. This strongly supports it as the likely causative agent for the dermatitis. Boarding the ventilation panes and use of insect spray were successfully implemented to control the outbreak. Increased awareness of this condition is important to prevent misdiagnosis.

[Biological properties of heat-labile lethal toxin of Yersinia pseudotuberculosis].

The aim of the study was to assess the biological properties of heat-labile lethal protein toxin of Y. pseudotuberculosis. Toxin was extracted from Y. pseudotuberculosis strain 2517 type III serovar pYV-. The toxin killed mice 1-3 days after intraperitoneal administration (LD50=0.3 mcg of the protein). Heating at 56 degrees C during 30 min inactivated lethal activity of the toxin. It had a dose-dependent dermonecrotic effect during intracutaneous administration in rabbits. Hyperimmune rabbit serum to the toxin was obtained. Incubation of the toxin (LD100=1.2 mcg of the protein) with the serum at 37 degrees C during 30 min resulted in neutralization of lethal and dermonecrotic effects. The toxin did not have the cytotoxic effect on HeLa, Hep-2, and SPEV cells, but showed hemolytic activity to human and animal erythrocytes, and weak mitogenic activity to splenic cells of CBA line mice compared with control mitogen (concanavalin A).

Reacciones cutáneas a tratamientos farmacológicos y cosméticos / Cutaneous reactions to pharmacologic and cosmetic treatments

En la actualidad, una de las causas más frecuentes de biopsia en la patología cutánea no tumoral son las reacciones cutáneas a fármacos o cosméticos. Además, la continua aparición de nuevos tratamientos farmacológicos y cosméticos obliga a estar preparado para reconocer sus posibles efectos adversos en la piel. Éstos pueden manifestarse en forma de prácticamente todas los patrones histopatológicos e incluso desencadenando la aparición de una dermatosis en individuos propensos a ésta. El diagnóstico de las toxicodermias se basa, como en la gran mayoría de enfermedades dermatológicas, en la correlación clínico-patológica. No obstante, existen unos hallazgos microscópicos que nos pueden sugerir esta posibilidad diagnóstica como por ejemplo la eosinofilia, la disqueratosis y la asociación de patrones histopatológicos inhabituales o aparentemente incongruentes

At the present time, one of the leading causes of biopsy among non-tumoral dermatological diseases is skin reaction to cosmetics or drugs. Due to the continuous advent of new pharmacological treatments and the appearance of novel cosmetic procedures, pathologists must be prepared to recognize their cutaneous adverse reactions. These reactions can adopt practically every histopathological pattern and even trigger the appearance of a dermatosis in a predisposed individual. As in most other dermatological diseases, the diagnosis of cutaneous adverse drug reactions is based on clinico-pathological correlation. Nevertheless, there are some histopathological clues that can suggest this diagnosis such as the presence of eosinophilia and/or dyskeratosis and the combination of unusual and apparently incongruent histopathological patterns

Reacciones cutáneas a tratamientos farmacológicos y cosméticos / Cutaneous reactions to pharmacologic and cosmetic treatments

En la actualidad, una de las causas más frecuentes de biopsia en la patología cutánea no tumoral son las reacciones cutáneas a fármacos o cosméticos. Además, la continua aparición de nuevos tratamientos farmacológicos y cosméticos obliga a estar preparado para reconocer sus posibles efectos adversos en la piel. Éstos pueden manifestarse en forma de prácticamente todas los patrones histopatológicos e incluso desencadenando la aparición de una dermatosis en individuos propensos a ésta. El diagnóstico de las toxicodermias se basa, como en la gran mayoría de enfermedades dermatológicas, en la correlación clínico-patológica. No obstante, existen unos hallazgos microscópicos que nos pueden sugerir esta posibilidad diagnóstica como por ejemplo la eosinofilia, la disqueratosis y la asociación de patrones histopatológicos inhabituales o aparentemente incongruentes

At the present time, one of the leading causes of biopsy among non-tumoral dermatological diseases is skin reaction to cosmetics or drugs. Due to the continuous advent of new pharmacological treatments and the appearance of novel cosmetic procedures, pathologists must be prepared to recognize their cutaneous adverse reactions. These reactions can adopt practically every histopathological pattern and even trigger the appearance of a dermatosis in a predisposed individual. As in most other dermatological diseases, the diagnosis of cutaneous adverse drug reactions is based on clinico-pathological correlation. Nevertheless, there are some histopathological clues that can suggest this diagnosis such as the presence of eosinophilia and/or dyskeratosis and the combination of unusual and apparently incongruent histopathological patterns

Concepts in molecular dermatotoxicology.

In the recent years, molecular research has successfully elucidated some of the major mechanisms through which environmental noxae damage human skin. From this knowledge, novel concepts for skin protection have been developed. Here, we provide a brief overview of some of the most exciting and intriguing concepts in molecular dermatotoxicology.

Lateral gene transfer of a dermonecrotic toxin between spiders and bacteria.

MOTIVATION: Spiders in the genus Loxosceles, including the notoriously toxic brown recluse, cause severe necrotic skin lesions owing to the presence of a venom enzyme called sphingomyelinase D (SMaseD). This enzyme activity is unknown elsewhere in the animal kingdom but is shared with strains of pathogenic Corynebacteria that cause various illnesses in farm animals. The presence of the same toxic activity only in distantly related organisms poses an interesting and medically important question in molecular evolution. RESULTS: We use superpositions of recently determined structures and sequence comparisons to infer that both bacterial and spider SMaseDs originated from a common, broadly conserved domain family, the glycerophosphoryl diester phosphodiesterases. We also identify a unique sequence/structure motif present in both SMaseDs but not in the ancestral family, supporting SMaseD origin through a single divergence event in either bacteria or spiders, followed by lateral gene transfer from one lineage to the other.

Dermatoxin and phylloxin from the waxy monkey frog, Phyllomedusa sauvagei: cloning of precursor cDNAs and structural characterization from lyophilized skin secretion.

Amphibian skin is a morphologically, biochemically and physiologically complex organ that performs the wide range of functions necessary for amphibian survival. Here we describe the primary structures of representatives of two novel classes of amphibian skin antimicrobials, dermatoxin and phylloxin, from the skin secretion of Phyllomedusa sauvagei, deduced from their respective precursor encoding cDNAs cloned from a lyophilized skin secretion library. A degenerate primer, designed to a highly conserved domain in the 5'-untranslated region of analogous peptide precursor cDNAs from Phyllomedusa bicolor, was employed in a 3'-RACE reaction. Peptides with molecular masses coincident with precursor-deduced mature toxin peptides were identified in LC/MS fractions of skin secretion and primary structures were confirmed by MS/MS fragmentation. This integrated experimental approach can thus rapidly expedite the primary structural characterization of amphibian skin peptides in a manner that circumvents specimen sacrifice whilst preserving robustness of scientific data.

Proteome analysis of brown spider venom: identification of loxnecrogin isoforms in Loxosceles gaucho venom.

Brown spiders of the Loxosceles genus are distributed worldwide. In Brazil, eight species are found in Southern states, where the envenomation by Loxosceles venom (loxoscelism) is a health problem. The mechanism of the dermonecrotic action of Loxosceles venom is not totally understood. Two isoforms of dermonecrotic toxins (loxnecrogins) from L. gaucho venom have been previously purified, and showed sequence similarities to sphingomyelinase. Herein we employed a proteomic approach to obtain a global view of the venom proteome, with a particular interest in the loxnecrogin isoforms' pattern. Proteomic two-dimensional gel electrophoresis maps for L. gaucho, L. intermedia, and L. laeta venoms showed a major protein region (30-35 kDa, pI 3-10), where at least eight loxnecrogin isoforms could be separated and identified. Their characterization used a combined approach composed of Edman chemical sequencing, matrix-assisted laser desorption/ionization-time of flight mass spectrometry, and electrospray ionization-quadropole-time of flight tandem mass spectrometry leading to the identification of sphingomyelinases D. The venom was also pre-fractionated by gel filtration on a Superose 12 fast protein liqiud chromatography column, followed by capillary liquid chromatography-mass spectrometry. Eleven possible loxnecrogin isoforms around 30-32 kDa were detected. The identification of dermonecrotic toxin isoforms in L. gaucho venom is an important step towards understanding the physiopathology of the envenomation, leading to improvements in the immunotherapy of loxoscelism.

Paederus dermatitis in northern Iran: a report of 156 cases.

BACKGROUND: Paederus dermatitis develops when beetles of the genus Paederus (often called rove beetles) are crushed on the skin, releasing the vesicant pederin. These beetles are found in many tropical and subtropical habitats. METHODS: We describe 156 patients who presented to a dermatology clinic in the Guilan province of northern Iran during a 6-month period (May-October 2001). RESULTS: The peak time of presentation was in September, and the face and neck were the most common sites of involvement. Clinically, the most common presentation comprised geographic erythematous plaques with micropustules. In three-quarters of patients, more than one lesion was present. Kissing lesions were seen in 5% of cases, and 15% of patients developed diffuse desquamation. The majority of patients resided within 1 km of rice fields and used fluorescent lighting at home. In half of the cases, another family member was also affected. CONCLUSIONS: Paederus dermatitis is a common skin condition in northern Iran. We believe that increased public awareness of this condition can decrease mucocutaneous exposure to pederin.