Severe hepatic injury following suspected inadvertent oral exposure to topical psoralea tincture applied periorally in a 3-year-old boy: a case report and literature review

Psoralea corylifolia is widely used in China, India, and other countries for conditions such as vitiligo, neoplastic diseases, osteoporosis, rheumatoid arthritis, and inflammatory bowel disease. Modern studies have shown that active constituents of Psoralea corylifolia may possess hepatotoxicity and nephrotoxicity. Although processing may reduce the toxicity of some oral formulations, hepatic injury after oral administration of Psoralea preparations has been reported mainly in adults. In contrast, to our knowledge, no pediatric cases of hepatic injury associated with suspected inadvertent oral exposure to a topical Psoralea preparation have been previously reported. A 3-year-old boy developed vomiting, jaundice, and markedly elevated liver enzymes after psoralea tincture had been applied around his mouth for vitiligo for approximately one month. The topical preparation was discontinued after admission, and hepatoprotective therapy was started; however, liver injury continued to progress. The child was transferred to another tertiary care center and received further evaluation and treatment. Common viral, autoimmune, metabolic, biliary, and hematologic causes were not supported by the available investigations. Intravenous methylprednisolone followed by oral corticosteroid tapering was administered, together with continued hepatoprotective therapy. Third-party chromatographic analysis of the remaining topical preparation confirmed a high psoralen concentration, estimated at approximately 9.6–15.5 mg/mL. After prolonged follow-up, liver biochemistry eventually returned to normal approximately nine months after the first documented liver enzyme abnormality. This case suggests that repeated perioral application of a concentrated psoralen-containing topical preparation may be associated with severe, prolonged, but ultimately reversible liver injury in children. Clinicians should be alert to the potential systemic toxicity of herbal preparations in children, including orally administered products, topical preparations, and externally applied agents used near the mouth or on areas prone to licking or accidental ingestion.