HPI: The patient is a 59 yo woman with an eight month history of a pruritic dermatitis which began on the upper lip. It spread to the lower lip and recently to some fingers. For dental hygiene, she has used Crest toothpaste, a white ceramic nasal irrigator, dental floss, a WaterPic and a Sonic Dental Care apparatus on a daily basis. She has changed this protocol somewhat over the past few months. Initially, she used Desonide ointment for three to four weeks with minimal help. She also used clobetasol ointment 0.05% for 10 days with complete clearing. After a protocol of erythromycin gel, steroid ointment, protopic 0.03% the iritation largely disappeared. However, she continues to get flare ups with no apparent cause. Symptoms always include burning, itching and redness. She uses Vaseline on a regular basis to moisten and sooth her lips. A similar dermatitis has appeared around the nail of her right ring finger, and has lingered there for 3 months. In addition, her left ear has several similar spots, and other similar spots have come and gone around her eye lids, eye brow and forehead. Most recently, she has used tacrolimus 0.03% ointment with minimal help, and for the last few weeks only Vaseline, which seems to help the most. Because of the concern for "steroid addiction" of the facial skin, she only used topical steroids for short periods and only under close supervision. The process waxes and wanes unpredictably.
O/E: The process is localized, erythematous and scaly. The secondary lesions on the fingers and ears look similar.
Clinical Photos:
12/11/11
4/8/12
4/28/12
Laboratory:
Patch Test (T.R.U.E.) all 29 negative. More focused patch testing is indicated.
Lip culture: Staph epidermitis and alpha hemolytic strep (interpreted as normal skin organisms)
Biopsy: Considered, but not done at this time.
Diagnosis and Discussion: Initially, I presumed this to be an allergic contact dermatitis. I suspect that part of her regimen is the culprit. The sharp border is unusual and could suggest a koebnerized psoriasiform process from an oral hygiene devices that comes in contact with the area. In children, lip licking would be considered (lick eczema) but the history here does not support that diagnosis. If the process recurs, I would ask patient to let it develop and then biopsy the lesion. If that was not helpful, then patch testing with a dental tray would settle the issue of allergic contact dermatitis.
Questions: Have you encountered similar cases? What are your thoughts?
Reference:
1. This is a helpful reference which goes into the many causes of contact dermatitis around the mouth and lips. Available Free Full Text. Andrew Scheman, MD, et. al. Part 3 of a 4-part series Lip and Common Dental Care Products: Trends and Alternatives. Data from the American Contact Alternatives Group. Clin Aesthet Dermatol. 2011 September; 4(9): 50–53.
2. Here is another useful reference on persistent cheilitis, also available Free Full Text.
I agree we need to exclude allergic contact dermatitis by doing a patch test to standard series. If the patch test is negative to standard series, I am not sure if dental tray would be useful. How would one explain the lesions on the fingers and ears? Could this be due to secondary spread?
ReplyDeleteI think a more likely aetiology is this could be a endogenous process esp endogenous eczema triggered by some form of irritation from tooth paste. The lesion is too well demarcated but that does not exclude a irritant dermatitis. I would think psoriasis is a high possibility. Could this be lupus? Was it photosensitive? any serology for ANA done?
A more appropriate strength for topical tacrolimus should be 0.1% instead of 0.03%. Advise the patient to avoid local irritation from "strong" dental toothpaste. Use oral-B toothpaste which is much milder.
A small biopsy would confirm a spongiotic process, and further patch testing would then be indicated. Remote psoriasiform diagnoses are also in the differential, including paraneoplastic Bazex syndrome.
ReplyDeleteI agree that there may be a photo allergic component although she has some fissures in the nares that may indicate staph. Would she benefit from oral antibiotics to treat a perioral Derm picture and Topical tacrolimus .1%. Then she says I need a biopsy at some point if she’s had such extensive patch testing and has eruptions in other parts of the body
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