Journal of Clinical and Aesthetic Dermatology

OCT 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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45 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY October 2017 • Volume 10 • Number 10 C A S E R E P O R T nutritional supplement. He restarted the daily Ginkgo biloba/vinpocetine supplement two days prior to his follow-up appointment. After two doses, he again noted pruritus and macular erythema on the same area of his distal penis. In addition, similar to his initial exposure to the supplement, he commented that he felt smarter and that his libido was increased. He also noted that his heart rate was increased and that he had a stomach ache, similar to the first time he took the supplement. However, he had not shared this information prior to his repeat exposure to the agent. Cutaneous examination of his uncircumcised penis, after the foreskin had been pulled back, showed a 1mm red macule consistent with a telangiectasia. The right ventral distal penile shaft proximal to the corona also showed a 1x1cm area of mild erythema at the same location at which he had previously noted the skin lesion following his initial exposure to the Ginkgo biloba/vinpocetine agent (Figure 2). DISCUSSION Ginkgo biloba is the national tree of China and the official tree of Tokyo, the capital of Japan. It is a dioecious tree, divided into male and female species. The allogenic ginkgolic acid is present in the outer fleshy layer of the seeds within the ovules of the female trees. Therefore, when Ginkgo biloba trees are planted along streets for ornamental reasons, urban developers often recommend only planting the male trees (Figure 3). 1–3 The Ginkgo biloba leaf is the symbol of Tokyo. The leaf is fan-shaped with dichotomous venation—the veins radiate out into the leaf blade, sometimes splitting into two, but never anastomosing. The leaves are green and often notched or lobed; however, prior to falling, the leaves turn yellow during autumn (Figure 4). Ginkgo biloba leaves are usually collected when they are still green, between the months of July and September. The extract of the Ginkgo biloba leaf has been standardized (EGb 761) and contains 24% flavonoid glycosides, 6% terpene lactones, and less than five parts per million ginkgolic acid. The content of flavonoids (also referred to as phenylbenzopyrones or phenylchromones) varies between and within the seasons; greater amounts are present in the fall than in the spring. Ginkgolides and bilobalide are the two types of terpenoids. 1–3 The recommended dose of Ginkgo biloba extract to achieve therapeutic effectiveness has not been definitively determined; recommended doses range from 40mg to 60mg, three to four times daily for a possible minimum of eight weeks. Ginkgo biloba inhibits platelet- activating factor; therefore, caution should be used when considering this agent in patients taking warfarin, aspirin, or other antiplatelet medications. Conservative recommendations suggest discontinuation of Ginkgo biloba between 36 hours to 14 days before surgery. Other potential side effects of Ginkgo biloba include diarrhea, dizziness, headaches, nausea, vomiting, palpitations, restlessness, and weakness. 1–3 Mucocutaneous side effects from Ginkgo biloba have occurred following topical exposure to the fruit 4–6 or systemic exposure to the fruit 7 or leaf extract. 8,9 Both allergic and irritant contact dermatitis have been demonstrated following topical exposure to fruit; although Sower et al 4 emphasized that the dermatitis required the fruit to be ruptured and subsequent contact with the exposed juicy pulp, 4–6 other individuals also developed dermatitis after handling the intact fruit. 5 These patients FIGURES 1A–C. Front (A), back (B), and lateral (C) panels of the Ginkgo biloba/vinpocetine supplement taken by the patient FIGURE 2. After the foreskin was withdrawn, the right ventral distal penile shaft showed a small telangiectasia and a 1x1cm area of macular erythema; the red area appeared after the patient initially ingested the Ginkgo biloba/vinpocetine supplement and reappeared at the same location, consistent with a fixed drug eruption, following repeat exposure to the same agent.

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