Introduction

Bhilawa dermatitis is a very common contact dermatitis, which can present in both irritant and allergic contact dermatitis (ICD and ACD). In Indian scenario, it is very commonly used for driving away bad forces or forces of evil. Bhilawa is a common name for the marking nut, which is known as Semecarpus anacardium. It contains Allylcatechols, phenols, quinols, resorcinol; which are the reason for the irritant contact dermatitis. The sap of anacardiaceae of brown marking nut can cause reactions within a period of 10 minutes, whereas the sap from the black marking nut can cause reactions after 24 hours. The oleo resins present in the sap of the marking nut can cause both allergic and irritant reactions. The catechol present in the sap can bind to the proteins and they are not washable. Whereas the oleo resins can be dissolved with washing and the reactions are prevented.

Case reports

Case 1

A 43-year-old lady presented with severe chest pain since 1 week, there was pain only on one side and severe burning sensation. Similar history was present 1 month back and the second episode was more painful and extensive. There was no history of suffering with any immunosuppressive conditions nor she was on steroids. On examination, there were many vesicles to bullae on an extensive erythematous background extending from midline of the back to the midline of the chest (Fig. 1). On repeated history, she confessed to have applied the marking nut for relief of pain by a quack for the same.

Case 2

A 39-year-old man had come to the outpatient department with complaints of extensive itching with burning sensation on his scrotum, legs and hands immediately on the next day of drinking alcohol. He was perturbed and had taken treatment elsewhere as he was giving history of alcohol and drug intake for pain and was misdiagnosed as fixed drug eruption or erythema multiforme elsewhere. On repeated questioning he couldn’t find a valid reason for the eruption. We asked him to keep track of what is coming in contact with his body. Few days later again in the morning he had many tense clear fluid-filled blisters on forearm, legs (Fig. 2) and scrotum (Fig. 3). On repeated questioning, a history of application of marking nut extract to those areas was given.

Discussion

Marking nut dermatitis can cause both an ICD or an ACD. In patient 1, the Bhilawa was applied for the sake of pain relief and the patient would have presumed to have less pain as there would be an intense pain following the application of marking nut juice and then the patient presumes the pain has come down. She had actually gone to a cardiologist for the severe chest pain, the cardiologist duly diagnosed it as shingles/ herpes zoster and had given a dosage of acyclovir upon which it subsided but within a few weeks time, the skin eruption had erupted and then the cardiologist upon seeking the dermatologists opinion solved the mystery of application of marking nut.

In patient 2, the application scenario was very interesting. The patient did not have pain, neither any discomfort in the areas of legs, hands and scrotum before the day of alcohol intake, but used to develop the eruption following intake of alcohol. But, due to unbearable tantrums by him following his alcohol binge episode, his wife used to take 2-4 nuts, crush them to get an extract, thereafter apply that extract to the genitalia, hands and legs in his deep sleep. The patient was unaware of his better half to be so creative and on questioning the wife repeatedly, she confessed and had stopped doing so after proper counseling. The patient was also sent to a de-addiction center and he had given up alcohol by the end of 1 month.

Bhilawa dermatitis can present as many forms of ACD and ICD. As every one is aware of seven types of ICD, these uncommon forms are rarely seen and rarely pursued. These are erythema multiforme like, zoster like, vesiculobullous type, scabietic type, etc.

Prevention

Prevention is the best method of preventing contact dermatitis from reoccurring. Awareness should be done for the general public as it may cut down on the recurrence. Avoid contact with the marking nut.

Washing immediately with soap and water washes off by 50% if washed within 10 minutes, 25% if washed in 15 minutes and 10% if washed in 30 minutes. If washed after 60 minutes, none washes off.

SUGGESTED READING

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4. Bajaj AK, Saraswat A, Mukhija G, et al. Patch testing experience with 1000 patients. Indian J Dermatol Venerol Leprol 2007;73:313-8.
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6. Armstrong WP, Epstein WL. Poison oak: More than just scratching the surface. Hebalgram (American Botanical Council) 1995;34:36-42.
7. Ghorpade A. Contact dermatitis caused by Indian marking nut juice used to relieve ankle pain. Int J Dermatol 2014;53(2):e117-9.
8. Verma P, Chhabra N, Sharma R. Severe markingnut dermatitis. Dermatitis 2012;23(6):293-4.