What is Euphorbia Tirucalli (Poinsettia, Crown of Thorns, and Pencil Cactus)?
Euphorbiaceae is a large family of flowering plants that is found all over the world, which includes more than 8,000 different types of species. These plants are also known as the spurge family and they are divided into several subcategories or genera. Some of these plants, particularly those from the Euphorbia genus, have been used in traditional medicine throughout history to treat various health issues. Some common household and garden plants like the pencil cactus (Euphorbia tirucalli), crown of thorns (Euphorbia milii), and Poinsettia (Euphorbia pulcherrima) belong to this family.
Many plants from the Euphorbia species release a white, milky sap or latex, which can be harmful if it comes into contact with skin or mucous membranes, especially the eyes.
Consider the example of Euphorbia tirucalli, also known as pencil cactus, milk bush, and firestick plant. It typically grows like a shrub or a small tree without leaves, has branches that are similar to a succulent, and can reach heights of up to 12 meters. This plant produces large amounts of latex, especially when it’s damaged or broken. Although it’s native to Africa, it is commonly used for decorative purposes in southern United States. Because this plant often grows where people live, it’s important for healthcare providers in these areas to understand its potential for causing harm. In fact, Texas’s poison control center reported 678 incidents involving Euphorbia tirucalli between 2000 and 2018, although it’s likely that there’s a higher number of unreported exposures. Other plants from this family, such as Euphorbia myrsinites, Euphorbia marginata, Euphorbia peplus, and Euphorbia trigona can cause similar skin irritations after contact with their latex.
Skin contact with the latex typically causes a mild skin irritation. However, if this latex gets into the eyes, it is a medical emergency that may result in blindness if it’s not treated promptly. It’s quite rare for people to eat the latex, but if this occurs, it could lead to mild irritation in the mouth, throat, and stomach.
What Causes Euphorbia Tirucalli (Poinsettia, Crown of Thorns, and Pencil Cactus)?
The harmful effects of the sap or ‘latex’ from the Euphorbia plant has not been fully researched. However, it’s thought to cause damage to cells and inflammation in the body because it affects the natural pH balance, or acidity, within our cells.
This milky latex, known to have a burning effect, contains special compounds called alkaloids. When it touches the skin, it can cause a sort of skin irritation, similar to a chemical burn. If it gets into the eyes, the latex can cause a chemical injury to the clear window at the front of the eye (cornea) and the thin, delicate membrane that covers the front of the eye and the inside of the eyelids (conjunctiva). This is due to it raising the pH level in the eye, causing damage.
The latex contains substances known as Diterpenoids which are thought to play a part in how it harms cells. Another compound found in the sap of many Euphorbia plants is Ingenols, responsible for its damaging and inflammatory effects. Euphorbia peplus latex contains Ingenol mebutate, a compound that has been approved by the U.S. Food and Drug Association (FDA) for the topical treatment of sun-damaged skin spots (known as actinic keratosis). It is thought to work by causing rapid cell death and inflammation-driven effects.
Risk Factors and Frequency for Euphorbia Tirucalli (Poinsettia, Crown of Thorns, and Pencil Cactus)
The exact number of people affected by the harmful effects of Euphorbia latex, a plant substance, is not known. However, between 2000 and 2018, there were 678 incidents involving this substance reported by the Texas Poison Center Network. More than half of these cases were males, and most were adults aged 20 or over. Almost all of these incidents took place in the person’s own home.
- Anyone who handles these types of plants without the right protective gear is at risk of injury.
- Gardeners, landscapers, florists, and nursery workers might have a higher chance of being exposed.
Most of the time, contact with the toxic latex happens by accident, and people might not know what caused their symptoms. Young children may show more skin irritation after touching the latex compared to older children and adults. Swallowing the latex is not common and usually doesn’t lead to severe problems. Many people who only experience minor symptoms after touching Euphorbia latex might not go to the doctor.
Signs and Symptoms of Euphorbia Tirucalli (Poinsettia, Crown of Thorns, and Pencil Cactus)
If you come into contact with the latex from the Euphorbia plant, you may experience symptoms immediately or they might be delayed. The severity of these symptoms can vary, depending on the location and amount of contact. For instance, you could be doing some gardening and get the sap in your eye.
With skin contact, people often don’t realize that their symptoms are caused by the plant. Therefore, if you notice any new symptoms, consider whether you’ve been exposed to any new plants, chemicals, cosmetics, detergents, pets, or medications. Skin reactions to Euphorbia plant can include burning, pain, or itching. Severe irritation and pain can occur, but usually, symptoms are mild. They generally start 2 to 8 hours after exposure and then can gradually get worse.
If the latex from the Euphorbia plant gets in your eye, symptoms usually just start instantly. This might happen if the sap falls directly into your eye, or if you touch your eye after handling the plant. Symptoms can include severe pain, burning, tearing, light sensitivity, and even potential vision loss.
If the latex is swallowed, it may irritate your mouth and throat, causing burning, abdominal pain, nausea, and vomiting.
Doctors can confirm these symptoms with a physical examination. If you’ve had contact with the plant on your skin, the doctor might notice redness, tenderness, blisters, small fluid-filled sacs, blood spots, plaques, blood blisters, or ulcers. These areas will most likely be sensitive to touch and will probably be found on the hands or fingers which are the most common points of contact with the plant.
If you have eye symptoms, the doctor will conduct a thorough eye examination. This may reveal anything from mild inflammation of the eye lining to severe inflammation of the cornea and uvea, or even vision loss. The doctor will measure your visual acuity, test the pH level and pressure inside your eye, and do a slit-lamp examination. They may use a fluorescent dye to help detect corneal epithelial defects. After exposure to Euphorbia latex, it’s also possible to see increased pH level in the eye, eyelid swelling, eye-socket muscle spasm, inflammation of the conjunctiva, chemosis (swelling of the conjunctiva), corneal ulceration, corneal swelling, small points of corneal defects, cells in the anterior segment of the eye, lens flare, hypopyon (inflammatory cells in the anterior chamber of the eye), and raised intraocular pressure. However, there shouldn’t be any abnormalities in the examination of the fundus (back part) of the eye.
Testing for Euphorbia Tirucalli (Poinsettia, Crown of Thorns, and Pencil Cactus)
If you have come into contact with the sap (latex) of a Euphorbia plant, the first step is to make sure you thoroughly clean the area to prevent further harm. If it has gotten on your skin, wash it with soap and water. If you were wearing contact lenses, remove them. If it has gone in your eyes, rinse them out carefully with water or saline (salt water solution) for at least 30 minutes. If your eyes’ natural pH level gets too high, which can lead to discomfort, keep rinsing until it drops back to around 7, which is normal.
Typically, if you have only had skin or eye exposure to Euphorbia latex, you wouldn’t need laboratory tests or imaging scans, as these wouldn’t likely show any significant changes. However, if you’ve swallowed the latex and are experiencing system-wide symptoms like persistent vomiting or severe stomach pain, it might be wise to get blood tests done to check your electrolyte levels. In such cases, imaging of the chest or abdomen might also be carried out to check for other possible issues. These instances are, however, uncommon, so any tests would be decided upon based on your symptoms and your doctor’s observation.
If there’s a chance that someone intentionally swallowed Euphorbia latex, it might be useful to screen for other substances they could have also ingested, such as acetaminophen and salicylates. Along with these, regular tests like the electrocardiogram (ECG, a test to check the heart’s activity) would be performed. If it’s not clear what plant was ingested, your doctor may choose to check for cardiac glycosides – chemicals found in many plants that can affect the heart. This would involve a blood test checking for levels of digoxin, a type of cardiac glycoside. The results should only be used to confirm if cardiac glycosides are present, and not to quantify how much is in the system.
If there’s any uncertainty about the diagnosis or treatment, or if severe poisoning is suspected, it would be necessary to contact a poison control center for guidance.
Treatment Options for Euphorbia Tirucalli (Poinsettia, Crown of Thorns, and Pencil Cactus)
If you get Euphorbia latex (a type of plant sap) on your skin or in your eyes, or if you accidently swallow it, the main approach to treating the symptoms is supportive care. There’s no known cure-all for problems caused by Euphorbia latex.
For skin exposure, you can use oral (taken by mouth) antihistamines for itching and pain medicines for any discomfort. Over-the-counter medicines, like acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), are usually good enough to handle the pain. Creams or ointments that contain corticosteroids can help with local itching and swelling, but they could also delay the healing process. There’s no agreement on the use of these creams or ointments after exposure to Euphorbia latex, although they’re a common treatment for irritant contact dermatitis, which is a type of skin inflammation that happens after contact with certain substances.
If Euphorbia latex gets in your eyes, it’s important to thoroughly rinse the affected eye(s) and ensure they are at a pH level of approximately 7 (which is neutral). Drops that numb the eye, like ophthalmic tetracaine, might be used for pain relief during the exam, but they aren’t recommended for long-term use and shouldn’t be prescribed for use at home because they could harm the cornea if used for a long period. Eye drops made to mimic natural tears, oral NSAIDs, and acetaminophen can offer pain relief for eye symptoms. If the surface of your cornea is damaged, you might also need antibiotic eye drops to prevent a secondary bacterial infection. If you wear contact lenses, they may suggest an antibiotic like ophthalmic ciprofloxacin or ofloxacin that can kill Pseudomonas bacteria, which can cause infections in people who wear contact lenses. Steroid eye drops and cycloplegics, which cause the pupil to stay wide open, might also be prescribed for cases of keratouveitis (an eye condition). And if the pressure in your eye is too high, you might need medicines to lower it.
Ingesting Euphorbia tirucalli, a type of Euphorbia plant, usually only causes minor symptoms. Cold fluids, ice or ice cream can soothe your mouth if it feels irritated, while viscous lidocaine, a type of local anesthetic, may be considered for more severe cases. Activated charcoal might or might not work to neutralize or prevent absorption of Euphorbia sap. However, it could be given in cases of high plant consumption within 1 hour, assuming the patient is suitable for activated charcoal consumption. Treatments that might cause vomiting should be avoided because this can cause more damage to the esophagus. Usually, you don’t need gastric lavage, or stomach pumping, for minor ingestions, and this technique may not effectively remove large plant particles if present. In exceptionally rare cases of consuming a significant volume of Euphorbia plant material or latex, doctors may consider whole bowel irrigation, a procedure to remove the toxin from your body. For mild to moderate symptoms of gastroenteritis—a condition that causes irritation and inflammation of the stomach and intestines—treatment with anti-nausea medicines and proton-pump inhibitors, which reduce stomach acid production, would be suitable.
What else can Euphorbia Tirucalli (Poinsettia, Crown of Thorns, and Pencil Cactus) be?
If a patient has been in contact with plants but cannot confirm it, diagnosing the condition can be a bit tricky. Whenever skin reactions appear, doctors should keep in mind that these reactions could be from irritant contact dermatitis (ICD), which can be caused by exposure to various things like acids, solvents, metals, cosmetics, and even plants.
Other skin conditions such as allergic contact dermatitis, atopic dermatitis, skin reactions due to medications, and infections also need to be taken into account. Specifically, fungal skin infections like tinea corporis and tinea manuum can look a lot like ICD. Scabies, which tends to affect the skin folds on the hands and causes severe itching, can be distinguished from plant-induced dermatitis (phytodermatitis) with a thorough medical history and skin check.
There are many plants beyond the Euphorbiaceae family that can cause skin irritation. For example, the well-known stinging nettle produces an itchy, hive-like skin reaction upon touch due to its irritating hairs. Common house plants such as Philodendron and Dieffenbachia as well as some flower bulbs like tulips, hyacinths, and daffodils carry irritating calcium oxalate crystals.
If exposed, these crystals cause localized irritation and swelling, particularly when they come into contact with moist surfaces like the inside of the mouth. Poison ivy, poison oak, and poison sumac all provoke allergic contact dermatitis, a common immune reaction to certain substances.
Other plants, including citrus, celery, parsley, and parsnips, which contain furocoumarins, can cause phytophotodermatitis, a skin condition that may resemble different types of skin inflammation. Skin reactions limited to areas exposed to sunlight might imply a light-sensitivity reaction.
Given that eye symptoms can present immediately after exposure to Euphorbia latex, a type of plant, doctors will often take this as a clue to identify the culprit. However, they will also consider the possibility of exposure to chemicals including acids, solvents, or other harmful agents. The good news is that the treatment is generally the same regardless of the source of irritation.
What to expect with Euphorbia Tirucalli (Poinsettia, Crown of Thorns, and Pencil Cactus)
The overall outlook for those exposed to the sap of the Euphorbia tirucalli plant is generally very good. Initial symptoms of skin irritation may get worse over a few hours following exposure but usually get better within 3 to 4 days.
The level of harm to the eyes depends on how much sap has made contact with the eye and for how long. Even when the eye is rinsed out properly and promptly, eye pain and vision disturbances may continue to get worse over the first 1 to 2 days following exposure.
Damages to the surface of the eye, known as corneal epithelial defects, typically heal within 4 to 7 days, but in some instances, it may take up to 10 days. With quick and proper treatment, most people will completely recover all signs and symptoms, including their vision, within 1 to 2 weeks.
Possible Complications When Diagnosed with Euphorbia Tirucalli (Poinsettia, Crown of Thorns, and Pencil Cactus)
It’s rare to have complications after coming into contact with Euphorbia latex, but serious outcomes such as blindness have occurred. Skin exposure doesn’t usually result in complications, but the affected skin spots could be prone to bacterial infections.
People with damaged surface layer of the eye (corneal epithelial defects) are more likely to get bacterial eye infections. If left untreated, scarring on the cornea (front surface of the eye), the formation of a bulge in the eye (anterior staphyloma), new blood vessels forming in the cornea (corneal neovascularization), and blindness might potentially occur.
Possible Risks:
- Potential for bacterial infections in affected skin areas
- Risk for bacterial eye infections in patients with corneal epithelial defects
- Potential for corneal scarring without treatment
- Possibility of anterior staphyloma without treatment
- Possibility of corneal neovascularization without treatment
- Potential for blindness without treatment
Preventing Euphorbia Tirucalli (Poinsettia, Crown of Thorns, and Pencil Cactus)
If someone comes into contact with the sap from a Euphorbia plant, it’s essential to be aware that this plant is toxic. So, they should try to avoid any similar plants if possible. If a person needs to interact with these kinds of plants, they should protect themselves from direct touch. This can be done by wearing personal protective equipment (PPE) like gloves and safety goggles.
After handling the plant or its sap, any gloves or clothing that were worn should be immediately washed clean. Also, any Euphorbia plants that are being kept for decoration should be placed outside the reach of both small kids and pets.
If there is a chance of coming into contact with such toxic plants again in the future, it would be helpful to take photos of these plants. These pictures can then be shown during any future medical check-ups for advice or guidance.
