Contact cheilitis in Singapore

Prevalence and causative allergens of contact cheilitis in Thailand

BACKGROUND

Cheilitis is an inflammatory condition of the lips. Its causes can be exogenous (irritants, allergens), endogenous (atopic dermatitis, systemic disorders) or unknown.

OBJECTIVES

To determine the prevalence of allergic contact cheilitis (ACC), its risk factors, and common allergens in patients with cheilitis at a Thai university-based tertiary care hospital.

METHODS

A retrospective chart review was conducted on patients with cheilitis referred for patch testing between January 2007 and December 2021.

RESULTS

Among 5366 patients referred for patch testing, 410 (7.6%) had cheilitis. ACC was diagnosed in 32% of the cheilitis patients. Compared to non-ACC cases, the patients with ACC were more likely to be young and female and have a disease duration of <3 months, no underlying disease and a white-collar job (p-value <0.05). The most common contact allergens were patient's products (73.3%), nickel sulfate (29.8%), potassium dichromate (14.5%), castor oil (14.3%) and benzalkonium chloride (13.0%). Lip cosmetics and toothpastes were major ACC sources.

CONCLUSIONS

ACC should be considered in cheilitis patients, especially in patients with specific risk factors. Castor oil is an emerging allergen. Patch testing using commercial allergen series and patients' own products is crucial for identifying causative agents. The development of a specific cheilitis series is warranted.

Prevalence and trend of allergen sensitization in patients with cheilitis referred for patch testing, North American Contact Dermatitis Group data, 2001-2018

BACKGROUND

An updated understanding of allergic contact cheilitis is needed.

OBJECTIVES

To characterize clinical characteristics and allergen relevance in patients with cheilitis referred for patch testing.

METHODS

Retrospective analysis of 43 772 patients patch tested with the North American Contact Dermatitis Group (NACDG) screening series from 2001 to 2018.

RESULTS

Overall, 2094 patients (4.8%) had lips as one of three sites of dermatitis, 1583 (3.6%) had lips as the primary site and 1167 (2.7%) had lips as the sole site of dermatitis. Prevalences of cheilitis at any, primary, and sole sites significantly increased throughout the study cycle from 2001-2002 (2.7%, 2.2% and 1.7%) to 2017-2018 (7.8%, 5.2% and 3.7%). Approximately 60% of patients with any, a primary, or a sole site of cheilitis had one or more positive allergic patch-test reactions compared to 65% of those without cheilitis.

CONCLUSION

Patients with cheilitis who were referred for patch testing had high rates of positive and relevant allergens. More than one in four patients with any, primary, or sole cheilitis had a positive reaction to non-NACDG screening allergens (28.0%, 26.8%, 31.1% vs. 21.6%) compared to patients without cheilitis, emphasizing the need for expanded patch test series in cheilitis.

Analysis of clinical presentations, lip transepidermal water loss and associated dermatological conditions in patients with chronic cheilitis

Chronic cheilitis (CC) is a spectrum of inflammatory changes of unknown etiology that affect the vermilion of the lips. This study aimed to describe the epidemiology, clinical presentations and risk factors of CC. Patients with CC were recruited from the National Clinical Research Center for Oral Disease of China. A convenience sample of inhabitants who live in the same geographical region were recruited as the control group. The lip skin transepidermal water loss (TEWL) and capacitance of CC patients were compared with that of age- and gender-matched controls. Our results demonstrated that of the 109 patients with CC, 72 (66.1%; 95% CI: 57.0-75.1%) were female. The common clinical presentations of CC consisted of desquamation (n = 99; 90.8%), and/or chapping (n = 81; 74.3%), and/or pruritus (n = 64; 58.7%). Multivariable analysis showed that allergic dermatologic diseases (P < 0.001; OR: 4.5; 95% CI: 2.4-8.4), anemia (P = 0.001; OR: 3.3; 95% CI: 1.5-7.5), and indoor/outdoor alternate working environment (P < 0.001; OR: 2.1; 95% CI: 1.5-2.8) were the significant risk factors for CC. The mean lip skin TEWL was found to be significantly higher, while the capacitance was lower in CC patients compared to that of control individuals. This study provides insights into the etiopathogenesis of CC and may help clinicians to identify the most effective management strategies.

Contact allergy to beeswax and propolis among patients with cheilitis or facial dermatitis

BACKGROUND

Beeswax, both white and yellow, has many uses, such as in lip balm. This material can cause contact allergy, although not many cases have been described.

METHODS

Ninety-five patients with contact cheilitis, facial eczema or a suspicion of contact allergy to beeswax were patch tested with yellow and white beeswax and with propolis, in addition to the Swedish baseline series. Patients who reacted positively to beeswax were additionally tested with caffeic acid, and two derivatives thereof that are believed to be important haptens in propolis.

RESULTS

Seventeen patients had positive reactions to beeswax. Fourteen of these patients had been tested with both yellow and white beeswax. Among those 14, eight had positive reactions to both types of wax, five only to yellow wax, and one only to white wax. Of the 10 wax-positive patients tested with caffeic acid derivatives, three reacted positively. Fourteen beeswax-positive patients also had positive reactions to propolis.

CONCLUSION

Patch testing cheilitis patients is important, as contact allergy is common. Our suggestion is to patch test, apart from the baseline series and the patient's own products, also with beeswax and propolis. Many beeswax-allergic cheilitis patients would not have been diagnosed with a relevant contact allergy if only the Swedish baseline series had been used.

Toxicology and pharmacology of sodium ricinoleate

Ricinoleic acid constitutes approximately 90% of the fatty acid content of castor oil. Castor oil is known for its purgative effects and can be used to induce labor. Both castor oil and ricinoleic acid are approved for use in food. The mechanistic basis for purgative actions likely includes the membrane-disruptive effects of detergent-like molecules, such as sodium ricinoleate (a 'soap'). These effects have been shown to be dose-related and to exhibit a threshold below which no laxative response was evident, in both animals and in humans. Castor oil was not toxic in subchronic feeding studies in rodents at doses ranging up to 10-20% of the diet. Sodium ricinoleate, as a surfactant, demonstrates predictable skin and mucus membrane irritant effects, and may induce a Type IV dermal sensitization response in those previously sensitized to it. However, food-grade castor oil and sodium ricinoleate are prepared in such a manner as to be free of the castor bean constituents that have been proven to be the source of reported Type I immediate hypersensitivity responses. Feeding studies with castor oil in rodents provide a basis for a no observable adverse effect level (NOAEL) estimate of 7,500 mg/kg/day and 5,000 mg/kg/day in mice and rats, respectively (). Applying an uncertainty factor of 100 to the lesser of these NOAELs, one can thus estimate an acceptable daily intake (ADI) in man to be 50 mg/kg, or 3,000 mg of castor oil per day in an average 60 kg person. As ricinoleic acid constitutes approximately 90% of castor oil, applying this calculation to the 3,000 mg/day estimated ADI in humans for castor oil (given the rapid hydrolysis of castor oil glyceride in the gastrointestinal tract), the acceptable daily intake of ricinoleic acid may be as high as 2,400 mg/person.

Cheilitis caused by contact urticaria to mint flavoured toothpaste

A 26-year-old woman presented with a 12-month history of persistent dermatitis of the lips. She had failed to respond to cosmetic avoidance and therapeutic measures. Patch testing was negative, including her toothpaste and toothpaste flavours. She defied diagnosis until an acute flare followed immediately after dental treatment with a mint flavoured tooth cleaning powder. This led us to prick test her to mint leaves and this was positive. Her cheilitis settled after changing from her mint-flavoured toothpaste. A diagnosis of contact urticaria should be considered in cases of cheilitis of unknown cause.

Lip cosmetics

Throughout the centuries, the beauty of lips has been extolled by poets, and painters; and people in many different cultures decorate their lips. Modern cosmetics are designed not only to beautify the lips but also to moisturize and protect them from environmental hazards. Familiarity with the ingredients used in lip cosmetics is essential to recognizing and diagnosing the adverse reactions that are associated with these products.

Allergic contact cheilitis

Allergic contact cheilitis describes a not uncommon inflammatory reaction of the lips. We reviewed its allergic causes, and suspect that the literature does not adequately document the frequency and etiologic factors involved.