An otherwise healthy woman in her 20s presented with a 3-week history of painful, pruritic edematous linear plaques on the right hand. The rash began when she was stung by a jellyfish while swimming at a North Carolina beach (Fig. 1A), and she was treated with oral loratadine and topical triamcinolone acetonide 0.1% cream with initial improvement of symptoms. Over the following weeks, however, the rash repeatedly subsided and flared, despite ongoing treatment with topical triamcinolone cream (Fig. 1B). Examination upon presentation revealed well-defined erythematous and indurated papules configured as a string of beads (Fig. 1C). Treatment with topical tacrolimus 0.1% ointment was initiated. At 3-month follow-up, the patient reported overall interval improvement but noted recurrent eruptions with pain, pruritus, and erythema at the site of injury requiring ongoing treatment with topical tacrolimus (Figs. 1D–F).Figure 1: Clinical presentation of dermatitis after jellyfish sting. A, Erythematous, urticarial papules in a string-of-beads configuration immediately after exposure. B–F, Evolution of persistent and intermittently flaring eruption over the following 3 months.Jellyfish envenomation is a common environmental injury in coastal regions. After cutaneous contact with a jellyfish tentacle, nematocysts containing a complex mixture of venomous toxins, enzymes, and antigens are discharged with a force of up to 5 lb/in2 into the victim's dermis, with subsequent dissemination of the venom into systemic circulation.1 Localized pain is often identified rapidly after envenomation, and cutaneous findings include linear, erythematous, and edematous papules. Systemic reactions, including nausea, vomiting, diarrhea, and anaphylaxis, may also occur.1 Treatment of acute dermatitis is largely supportive and directed toward the management of any associated pain and pruritus. Most cases generally improve within days to weeks. Chronic, recurrent dermatitis after envenomation, however, is rarely reported.2 It is thought to arise from persistent nematocysts embedded within the dermis, which can lead to recurrent release of venom after mechanical trauma or friction, or the development of delayed, cell-mediated hypersensitivity reactions and venom antigen cross-reactivity.1 Occasionally, chronic eruptions distant to the initial sting may occur as well.3 Diagnosis of chronic dermatitis after jellyfish envenomation is typically made based on history and physical examination. Improvement after treatment with topical steroids, topical calcineurin inhibitors, and intralesional steroids has been reported.2 Time to complete resolution may vary widely, with prior cases reporting recurrence of cutaneous eruptions between 5 days and 18 months after the inciting injury.1–3 Identification of the species of causative jellyfish can be difficult at the time of injury; in this case, envenomation with an Atlantic sea nettle (Chrysaora quinquecirrha) was suspected given the geographic location of the patient's injury and the prevalence of this species along the North Carolina coast.4 Importantly, the risk for environmental dermatoses, injuries, and trauma, including jellyfish envenomation, has been projected to increase as a result of the rapidly increasing pace of climate change.5 Global populations of jellyfish have skyrocketed over the past 2 decades because of anthropogenic environmental changes favorable to jellyfish growth, including increased ocean temperatures, hypoxia, and acidification.5 Recognition of the impact of climate change on human health, including dermatologic disease, is a critical step in understanding and addressing the global climate crisis. Dermatologists should be aware of the growing burden of jellyfish envenomation and other environmental dermatoses.
