Severe contact cheilitis from cera alba and other cosmetic oils, fats and waxes in lip balms

A 32-year-old atopic female patient was referred because of a severe cheilitis lasting a few months, together with a longer standing, yet mild, facial and hand dermatitis. Initially, she had suffered from dry cracked lips, diagnosed as atopic cheilitis, for which she had tried multiple (n= 6) lip balms (Table 1). Clinical examination showed a pronounced lip dermatitis complicated by bacterial superinfection (Staphylococcus aureus, Pseudomonas aeruginosa; Figure 1). Peroral ciprofloxacine, topical acetic acid 1% aq. compresses and betamethasone-17-valerate 0.1% ointment were prescribed, and she was advised to use unscented toothpaste (oraNurse, Welwyn, UK), and petrolatum jelly as lip balm. Patch tests were performed with a baseline, cosmetic, fragrance and bakery series (Chemotechnique Diagnostics, Vellinge, Sweden), together with four of six suspected lip balms (two not available for patch testing). The tests, mounted on AllergEAZE chambers (SmartPractice, Calgary, Canada), were applied on the upper back for 2 days and readings were performed on Day (D)2, D4 and D7 (Table 1). These showed + to ++ reactions to the four lip balms, and to several haptens (all +): fragrances (Myroxylon pereirae, propolis, fragrance mix I [FM-I], limonene and linalool hydroperoxides), colophonium, octylisothiazolinone (OIT), 2-hydroxyethyl methacrylate (HEMA), and sorbitan sesquioleate (SSO). Although SSO positivity potentially explained the positive patch tests to M. pereirae, FM-I and HEMA, the patient also reacted to limonene hydroperoxides, whichwas considered relevant for the cheilitis, facial and hand dermatitis as limonene was declared in several of her cosmetics, including her toothpaste. No relevance was found for SSO, HEMA, colophonium nor OIT. As only one of four tested lip balms was effectively scented, additional patch tests were performed with (non-commercialized) patch test preparations obtained from cosmetic manufacturers. On that occasion+ reactions were observed to four oils, fats and waxes: cera alba (beeswax) 30% pet., candelilla cera (Euphorbia cerifera) 41% pet., butyrospermum parkii (shea butter) 30% pet. and helianthus annuus seed oil 10% pet., present in 5/6, 1/6, 4/6 and 1/6 of previously used lip balms, respectively (Table 1). All four haptens tested negatively in 20 control patients. The abovementioned treatment, together with the use of cosmetics free from all demonstrated allergens, lead to complete resolution of the cheilitis, and significant amelioration of the hand and face dermatitis.