Clinical AND Health Affairs Allergic contact cheilitis: four cases BY MOLLY C. GOODIER, KELLY A. ASCHENBECK, AND ERIN M. WARSHAW, MD, MS Case 1 17-year-old female presented with a tis and intermittent episodes of periorbital lergens, the patient’s dermatitis persisted. 5-year history of a pruritic, papular dermatitis (Figure 3A). Prior patch testing She was tested to a screening series and to A rash involving her lips (Figure 1A) had revealed positive reactions to lanolin other pertinent allergens. Testing revealed that was recalcitrant to topical and oral and bacitracin. Despite avoiding these al- a strong reaction to the patient’s Dr. Dan’s diphenhydramine, topical antibiotics, and TABLE 1 oral corticosteroids. Due to the duration of her persistent symptoms, she was re- Relevant Patch Test Reactions ferred to dermatology for possible allergic ALLERGEN CASE 1 CASE 2 CASE 3 CASE 4 contact dermatitis (ACD). Patch testing Sunscreens to several allergen series revealed a strong Benzophenone-3 ++ ++ positive reaction to benzophenone-3 (Fig- Fragrances/Flavors ure 1B), a sunscreen, which was identified in the patient’s Carmex lip balm. She also Balsam of Tolu ++ had a strong positive reaction to the lip Cinnamic alcohol ++ balm itself (Figure 1C). Other pertinent Cinnamic aldehyde ++ reactions are described in Table 1. Fragrance Mix I ++ Fragrance Mix II ? Case 2 Limonene + A 65-year-old female presented with a Menthol ++ 1.5-year history of dermatitis primarily Peppermint + involving her lips (Figure 2A). Her symp- Anesthetics toms had not improved with over-the- counter topical hydrocortisone or a topical Lidocaine + anesthetic. Patch testing showed a strong Dyes reaction to menthol and a mild reaction Carmine + to propolis, or bee glue (Figures 2B and Emollients C), both of which were identified in the Lanolin + patient’s Carmex lip balm, to which she Propolis + also reacted (Figure 2D). Additionally, the Personal Products patient had a mild reaction to lidocaine, Carmex lip balm ++ ++ which was present in the Medi Quattro Medi Quattro First Aid Cream + First Aid Cream she was applying to the area. This patient also reacted to a number Sensodyne Fresh Mint toothpaste + of flavoring agents that can be found in Dr. Dan’s CortiBalm lip balm ++ oral hygiene products, drinks, and food. Revlon ColorBurst Lip Butter ? Other pertinent reactions are described in L’Oreal Paris Caramel Comfort lip balm ? Table 1. Neosporin Lip Health Daily Hydration + LEGEND Case 3 ++ = strong (edematous or vesicular) A 42-year-old woman presented with an + = mild (erythema and infiltration, possible papules) approximate 1-year history of lip dermati- ? = doubtful (macular erythema) JULY/AUGUST 2017 | MINNESOTA MEDICINE | 35 Clinical AND Health Affairs CortiBalm lip balm (Figure 3B). Mild re- FIGURE 1 actions were noted to propolis and to car- mine (Figures 3C-E), a red dye frequently found in cosmetics such as lipsticks. Propolis was identified in her Dr. Dan’s lip balm. Other pertinent reactions are listed in Table 1. Case 4 A 62-year-old woman with a 10-year his- tory of perioral dermatitis (Figure 4A) accompanied by occasional irritation of the buccal mucosa presented for patch FIGURE 2 testing. Desonide and tacrolimus had been applied in the past without significant im- provement. Patch testing showed a strong reaction to benzophenone-3 (Figure 4B) with a mild reaction to her Neosporin Lip Health Daily Hydration Therapy personal product (Figures 4C and D), which was confirmed to contain benzophenone-3. Additional pertinent reactions are listed in FIGURE 3 Table 1. Discussion Allergic contact cheilitis (ACC) is a de- layed-type cutaneous hypersensitivity re- action affecting the lips. Typically, patients present with lips that are dry, scaly, and FIGURE 4 fissured, a condition that often spreads be- yond the vermillion border to involve the perioral area. Vesicles and edema may also be present.1 Females are more likely than males to be affected,2 which may be due to allergens in cosmetics.3 Common allergens implicated in ACC include fragrances and flavorings, nickel, FIGURE 1 Case 1 clinical photographs. (A) Minimal diffuse erythema predominantly involving patient’s lower lip. 3 (B) Strong patch test reaction to benzophenone-3. (C) Strong patch test reaction to Carmex personal product and cosmetic ingredients. Fragrances containing benzophenone-3. and flavors can be found in cosmetics and FIGURE 2 Case 2 clinical photographs. (A) Bright pink erythema of the lips with prominent xerosis and scale extending beyond the vermillion border. (B) Strong reaction to menthol. (C) Mild reaction to propolis. (D) Strong personal hygiene products such as tooth- reaction to Carmex personal product containing menthol and beeswax. pastes and mouthwashes. Nickel, the most FIGURE 3 Case 3 clinical photographs. (A) Circumferential erythema and scale extending beyond the vermillion common allergen identified in skin patch border. (B) Strong reaction to Dr. Dan’s CortiBalm lip balm. (C) Mild reaction to lanolin. (D) Mild reaction to propolis. 4 (E) Mild reaction to carmine. testing, may cause ACC through direct FIGURE 4 Case 4 clinical photographs. (A) Circumferential erythema extending down the bilateral marionette contact of the lips with metal items such lines, left greater than right. (B) Strong reaction to benzophenone-3. (C) Mild reaction to Neosporin Lip Health Daily Hydration Therapy. (D) Patient’s personal lip products. as musical instruments, dental appliances,5 and metal-rimmed drinking bottles. these emulsifiers help perpetuate a vicious In addition to the aforementioned Other cosmetic ingredients, includ- cycle, wherein the dryness from ACC is compounds, sunscreens may serve as ing lanolin and propylene glycol, may subsequently treated with the offending another source of ACC. Sunscreen agents also be responsible for ACC. The dual agent leading to continuation of symp- such as benzophenone-3 (also known as allergenic and moisturizing properties of toms. Propylene glycol is frequently found oxybenzone) are becoming increasingly in personal care products and topical more common in cosmetic products, as corticosteroids, while lanolin is a common ingredient in lip balms and lipsticks.6,7 36 | MINNESOTA MEDICINE | JULY/AUGUST 2017 Clinical AND Health Affairs consumers become more conscientious about preventing expo- REFERENCES sure to UV rays.8 Benzophenone-3 is a broad-spectrum chemical blocker that absorbs both UVA and UVB radiation. It is the most 1. Rietschel RL, Fowler JF. Fisher’s Contact Dermatitis. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001. common sunscreen agent to cause allergic contact sensitization9; 2. Zug KA, Kornik R, Belsito DV, et al. Patch-testing North American lip dermatitis among 219 patients with contact allergy to sunscreen agents, patients: data from the North American Contact Dermatitis Group, 2001 to 2004. benzophenone-3 was the culprit allergen in the majority of cases.8 Dermatitis. 2008;19(4):202-208. 3. Zoli V, Silvani S, Vincenzi C, Tosti A. Allergic contact cheilitis. Contact Dermatitis. Benzophenone-3 can induce both ACD and photoallergic der- 2006;54(5):296-297. 9 matitis. Sunscreen agents like benzophenone-3 can also “hide” 4. Warshaw EM, Maibach HI, Taylor JS, et al. North American Contact Dermatitis in products not advertised to have sun protection properties (eg, Group patch test results: 2011-2012. Dermatitis. 2015;26(1):49-59. 5. Schultz J, Connelly E., Glesne L, Warshaw EM. Cutaneous and oral eruption nail polish, shampoo, and perfumes), where it is used to prevent from oral exposure to nickel in dental braces. Dermatitis. 2004;15(3):154-157. photodegradation and discoloration. As a result, benzophenones 6. Warshaw EM, Botto NC, Maibach HI, et al. Positive patch-test reactions to were named Contact Allergen of the Year for 2104 by the Ameri- propylene glycol: a retrospective cross-sectional analysis from the North American Contact Dermatitis Group, 1996 to 2006. Dermatitis. 2009;20(1):14-20. can Contact Dermatitis Society to raise awareness of these ubiq- 7. Warshaw EM, Nelsen DD, Maibach HI, et al. Positive patch test reactions to 10 uitous and potentially unexpected allergens. lanolin: cross-sectional data from the North American Contact Dermatitis Group, Carmine, a dark red pigment derived from an aluminum salt 1994 to 2006. Dermatitis. 2009;20(2):79-88. 11 8. Warshaw EM, Wang MZ, Maibach HI, et al. Patch test reactions associated with harvested from the cochineal insect, is often used for its colorant sunscreen products and the importance of testing to an expanded series: retro- properties. It can be found in red cosmetics (eg, blush, lipstick, spective analysis of North American Contact Dermatitis Group data, 2001 to 2010. Dermatitis. 2013;24(4):176-182. and eye shadow), medicines, textiles, and foods (eg, yogurt, ice 9. Heurung AR, Raju SI, Warshaw EM. Adverse reactions to sunscreen agents: epi- cream, and shrimp). There have been few reports of ACD from demiology, responsible irritants and allergens, clinical characteristics, and manage- carmine, and most have involved lip products.11,12 The specific ment. Dermatitis. 2014;25(6):289-326. 10. Heurung AR, Raju SI, Warshaw EM. Benzophenones. Dermatitis. 2014;25(1):3- inclusion of carmine in products that contact the lips (such as lip- 10. sticks and food) makes it an important allergen to consider when 11. Shaw DW. Allergic contact dermatitis from carmine. Dermatitis. ACC is suspected. 2009;20(5):292-295. 12. Sarkany I, Meara RH, Everall J. Cheilitis due to carmine in lip salve. Trans St The differential diagnosis of ACC is broad. Angular cheilitis, Johns Hosp Dermatol Soc. 1961;46:39-40. which can also be associated with ACC, can develop alone from mechanical injury, infection (eg, Candida), or a systemic process. Other infectious etiologies include herpes labialis, which presents with clusters of vesicles on an erythematous base. Additionally, lip licker’s eczema (especially common in children) and irritant con- You have worked hard. tact dermatitis may have similar presentations to ACC.