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LIP COSMETICS
DERMATOLOGIC ASPECTS OF COSMETICS
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LIP COSMETICS Patricia G. Engasser, MD
”The lips are two fleshy folds which surround the orifice of the mouth, formed externally by integument and internally by mucous membrane, between which are found the Orbicularis oris muscle, coronary vessels, nerves, areolar tissue, and fat and numerous small labial glands.”17This anatomic description of human lips appeared at the beginning of the twentieth century. In the new millennium, it is understood that lips are much more than the sum of their parts.
HISTORY
Through the centuries, the beauty of the lips has been extolled by poets and painters. Red, full, moist, relaxed, slightly parted lips are considered sensuous. People in primitive cultures have stretched lips to gigantic proportions by inserting wooden disks; in more advanced developed countries, people plump the lips up by implanting bovine collagen and Gore-Tex threads.20Egyptian and Assyrian women painted their lips with plant material thousands of years ago. In the eighteenth century, Japanese women painted rouge on their mouth in a classic ochoboguchi style to express innocence, and contemporary Japanese brides continue this custom.32Rouging lips alternatively has been indulged or
scorned by societies. Following the Victorian era in 1915, its popularity grew again, and Levy persuaded the Scovill Manufacturing Company to produce lip rouge in a handy stick that was sold in a push-up case.41Lipstick was created, and the swivel case soon followed. In 1919, the Morton Manufacturing Company, in Lynchburg, VA, began the manufacture of Chap Stick, a lip balm to treat dryness and peeling. By 1946, American women spent around $30 million yearly for 5000 tons of lipstick that was available in a wide array of shades.32 In the 1950s, Revlon first rhapsodized their shades with romantic titles such as Fire and Ice and Cherries in the Snow, dramatizing this in elaborate, color, pictorial advertisements in women’s magazines. Fashion is fickle, and pale lip colors prevailed in the early 1970s, but women continued to apply lipstick. In the 1990s, dazzling colors created with newer pigment technology boost the sales of these ever-popular cosmetics. Lipstick‘s appeal extends to women of all ages; it frequently is the first cosmetic used by adolescents, and elderly women apply it daily. Many women do not feel dressed without it. Recovering patients apply lipstick because they feel better, and their appearance with the lipstick gives them a psychologic boost. Most women in the United States present a face to the world that has colored lips.
From the Department of Dermatology, Stanford University School of Medicine, Stanford; and the Department of Dermatology, University of California San Francisco School of Medicine, San Francisco, California
DERMATOLOGIC CLINICS
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VOLUME 18 NUMBER 4 OCTOBER 2000
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CATEGORIES
Lipsticks Lipsticks are cosmetics applied to the vermilion border to impart color and to define shape as well as provide protection from environmental conditions. They commonly are solid mixtures of lipids that soften at body temperature for smooth application-they are designated as thermoplastic for this reason. In addition to the visual characteristics they impart, consumers expect these cosmetics to give a pleasant, smooth feeling to this area of mucous membrane, which becomes dry and peels easily. Lipsticks are left on the lips (75 to 300 mg per application) and must be safe to ingest. They should not have an unpleasant taste or odor. Lipsticks are composed of five categories of ingredients-waxes, emollients, marketing and functional ingredients, stabilizers, and colorants. Waxes Waxes give structure to lipsticks, and because no single wax provides ideal texture, heat stability, and application and wear characteristics, mixtures are used. The blends of waxes can be plant derived, such as carnauba, candelilla, and rice bran, or petroleum derived, such as paraffin, ceresin, microcrystalline wax, and polyethylene.
lar to the action of surfactants for an oil and water solution, but oleyl alcohol has a double bond, making it more susceptible to oxidation and rancidity. Fatty esters, such as octyl palmitate, increase slip and impart a lighter feel. By balancing the amounts of wax and emollients, the creator of a lipstick can determine if the cosmetic is one that is firm and resists feathering-a term used to describe the creeping of color up the fine lines around the mouth. Lipsticks with a high emollient content impart a lubricious feel and give a moist appearance that is considered alluring, but they do not stay on the lips as well. Longwearing lipsticks have higher wax content in relation to emollients to allow longer pigment deposition, but they feel drier to the consumer and are less glossy.* Silicones are a special class of polymers that have become popular additions to lipsticks in the 1990s. They are inert, inexpensive, and colorless, and some are volatile. Dimethicone imparts barrier properties and, when present at 1% concentration, can allow an antichapping claim to be made. Volatile silicones (e.g., cyclomethicone and low-molecular-weight dimethicones) act as oils on application. As the lipstick sets, these silicones evaporate, and the remaining pigments resist transfer to cups, glasses, and kissed cheeks. Transferresistant lipsticks have a matte or dry finish and do not have a lubricious gloss. They are generally sold in slender cases that snap shut to prevent evaporation.
Emollients Emollients plasticize the waxes. In addition to providing moisturization and emolliency for the lips, they modify the application characteristics of slip, tack, and drag. A critical balance of these characteristics in the product must be achieved for a desired esthetic result on the lips. Emollients impart gloss and allow pigment wetting and dispersion. Popular natural emollients include castor oil, jojoba oil, and lanolin derivatives. Synthetic esters, polymers for film forming, and hydrocarbons are other important components. Isostearyl alcohol is a liquid with a low melting point that wets pigments, allowing their dispersions in this lipid mixture. Oleyl alcohol wets pigments and acts as a coupling agent, which allows the combination of different oils simi-
Miscellaneous Enhancing Ingredients Miscellaneous enhancing ingredients include materials that add function or marketing appeal. For example, menthol or camphor is added to impart a cool sensation on application and to give the impression of active ingredients. Lipsticks are regulated as overthe-counter drugs when chemical or physical sunscreens are added, and they are labeled with a sun protection factor (SPF). Ordinary lipstick pigments generally do not provide more than a SPF 4 protection (R. Sandewicz, personal communication). The popularity of vitamins, antioxidants, and botanicals has led to their appearance in lipsticks. Flavoring agents are added, especially to lip salves, that appeal to younger consumers
LIP COSMETICS
as a selling point. Fragrance mixtures are common ingredients. In lipid preparations, masking agents are used to cover unpleasant odors (e.g., ethylene brassilate, mint, or menthol). Stabilizers
The shelf life of a lipstick is generally 2 to 5 years. Lipsticks usually are anhydrous and easier to preserve from bacterial contamination than formulations made with water. Emulsion lipsticks can be formulated to create a more emollient product, but they are uncommon.42Antimicrobials commonly used in lipsticks are the parabens and phenoxyethanol. These products often are preserved with antioxidants, such as butylhydroxyanisole (BHA) or one of the gallates, particularly when unsaturated lipids are present. Colorants
Market research has established that the most important reason for a consumer to purchase a lipstick is its color appeal. The range of colors is astonishing considering the pallet of the cosmetic chemist has been significantly diminished in the last 4 decades. In 1959, there were 116 certifiable colors approved for use in cosmetics in the United States, and that number has been reduced to 34 at present.31 Until the twentieth century, there was little regulation of the safety of colors added to foods, drugs, and cosmetics, with some deaths resulting. The 1938 Food, Drug, and Cosmetic Act required that each batch of organic colorants must be confirmed as conforming to established standards to be certified. The 1960 Color Additive Amendments allowed the Food and Drug Administration (FDA) to set limitations on the amounts of color used. The manufacturers were required to submit data on the safety of the colorants. Colorants are either organic or inorganic; approved inorganic colorants, such as titanium dioxide (Ti02) or iron oxides, do not require batch certification. In the United States, approved organic colors are designated for Food, Drug and Cosmetic (FD&C) or Drug and Cosmetic (D&C)groups, both of which may be used on mucous membranes or ingested, but the External Drug and Cosmetic
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(Ext. D&C) group cannot be allowed on mucous membranes or ingested and is unsuitable for lip cosmetics (Table 1). The European Community and the Japanese lists of approved colors differ in many respects from those of the United States. The Europeans have a larger number of approved colors and employ the Color Index number for identification.28 For lipsticks, insoluble pigments or lakes are used for coloring. Lakes are pseudopigments produced by precipitating water-soluble colorants with water-insoluble salts, such as aluminum hydroxide. Lakes are virtually insoluble, and they can be handled as pigments. Formerly the indelible lipsticks used bromo colors, such as eosin (D&C Red No. 21), but they left a cherry red color on the lips and are unpopular at present. Sophisticated complex colors are used in many modern lipsticks. The use of pearlized colors has brought dramatic changes. They produce reflectance similar to tiny mirrors or interference depending on the coating thickness for Ti02/ mica. Powders, such as organically modified clays, silica, mica, or polymethyl methacrylate, also absorb oils, reduce bleeding of colors, and can enhance the tactile sensation. Producing uniformly colored, esthetic lipsticks, which are stable under extreme environmental conditions, requires the talents and knowledge of an experienced cosmetic chemist. Lipsticks are heated during manufacture to 5" above the highest melting point of the waxes, the milled pigments are mixed in, and the batch is poured into molds. The molded
Table 1. COLORING AGENTS FOR LIP COSMETICS Certified
D&C Orange No. 5 D&C Red No. 6 D&C Red No. 7 D&C Red No. 21 D&C Red No. 22 D&C Red No. 27 D&C Red No. 28 D&C Red No. 30 D&C Red No. 33 D&C Red No. 36 D&C Yellow No. 10 FD&C Blue No. 1 FD&C Yellow No. 5 FD&C Yellow No. 6
Certification Not Required
Titanium dioxide Mica Zinc oxide Iron oxides Carmine Bismuth oxychloride Bronze powder Ultramarines
Dntafrom references 28 and 43.
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lipsticks are passed through a gas flame to create a smooth, shining surface for eye appeal. Lipsticks vary in functional characteristics depending on their composition (Table 2). Oils give slip, a lighter feel, more gloss, and a tendency for colors to bleed. Waxes add to the tack and drag, resulting in longer wear, less bleeding, and diminished gloss. Lip Liners. Lip liners are modified lipsticks used to define the outline of the lips and to deposit a high pigment content that is not mobile. These commonly are sold as pencils that can be sharpened, but they can be made in thin swivel containers. Lip liners are effective when the natural lip contour is being modified or corrective makeup is being applied. Using lip liners decreases the feathering of lipstick into the lines around aging lips. Lip Glosses. Lip glosses have little wax and high oil content and are not in molded sticks. These are sold in pots or containers with a wand for application. They have low color content and make the lips shine. Some of these are marketed to young consumers and are heavily fragranced and flavored with fruit flavoring. Glosses do not stay on the lips well and migrate into the lip lines in mature women. Liquid Lipsticks. Liquid lipsticks usually are anhydrous with less wax than conventional lipsticks. Similar to lip glosses, they are not molded into sticks, but liquid lipsticks contain a high pigment content that appears more transparent. They can be transfer resistant.
Lip Balms A lip balm is an over-the-counter drug defined as ”a drug product that relieves and
prevents dryness or chapping of the exposed surface of the lip.”I3 The vermilion border is devoid of sebaceous or salivary gland and dries easily. Chapping is a reaction to environmental conditions, especially to cold or hot dry winds. The keratin of the vermilion border becomes inflexible or brittle, then cracks and peels. Subjects may lick their lips or pick at the flakes, aggravating the condition. Lip balms provide a barrier of protection. To qualify as a lip balm, a product must contain one of the following: Allantoin, 0.5% to 2% Aluminum hydroxide gel, 0.15% to 5% Calamine, 1%to 25% Cocoa butter, 50% Dimethicone, 1%to 30% Glycerin, 20% to 45% Kaolin, 4% to 20% Petrolatum, 30% to 100% Shark liver oil, 3% White petrolatum, 30% to 100% Zinc acetate, 0.1% to 2% Zinc carbonate, 0.2% to 2% Zinc oxide, 1%to 25% Some of these ingredients could raise concerns about comedogenicity and exacerbating perioral comedones in patients with acne.36 Dermatologists find these products useful for treating the lip chapping that often accompanies oral retinoid the rap^.^
Lip Sunscreens Chemical sunscreening ingredients are added to a colorless lipstick or lip balm to attain usually an SPF of 8 or greater. Colored lipsticks also are incorporating sunscreening agents. Once the SPF claim is made, these lipsticks are regulated as over-the-counter drugs as well as cosmetics. Ordinary effective sunscreens for glabrous skin are less effective
Table 2. LIPSTICK FORMULATIONS Ingredients
Waxes Volatiles Oils/ semisolids Colors and uowders
Lip Gloss Creamy Lipstick Long-Wearing Lipstick Transfer-Proof Lipstick Lip Liner
3-8% None 70-8OYo 0-5%
10-15% None 60-70% 10-15%
15-20% None 50-6OYo 10-15%
10-15’Xo 35-40% lo-20% 10-20%
1525% Varies 40-50% 1525%
Adapted from Sandewicz R W Lip and nail product technology continuing education course, for the Society of Cosmetic Chemists, December 8, 1999; with permission.
LIP COSMETICS
for the lips because lip sunscreens must have unique properties of adherence that resist friction and licking
Lipstick Primers Lipstick primers, which come in stick or cream form, act as a foundation for lipstick to help it adhere and to fill in the fine creases around the mouth. They allow a smoother application of lipstick. Some women apply liquid facial makeup as foundation to prepare the lips.
Lipstick Overcoats Lipstick overcoats are applied over lipstick to prevent it from coming off. They may contain perfluoro compounds and powder of polymethyl methacrylate.I6
Lip Treatment Products An array of specialty lip cosmetics are being introduced that are similar to products used for facial skin care. Lip masks may incorporate exfoliating ingredients, and lip makeup cleansers ease removal of lipstick to avoid soiling bathroom linens. The real expansion has been in products that incorporate retinoids, alpha hydroxy acids, vitamins E and C, and other antioxidants, modeling themselves on the cosmeceuticals designed for other areas of the facial skin. There does not appear to be published documentation of their efficacy for the lip area.
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whose vision or motor skills are impaired so that they are unable to apply lipstick correctly. Some consumers choose lip tattooing because they want color that will not migrate into wrinkles, or they wish to avoid the bother of applying lipstick frequently. Because fashion changes constantly, the permanency of this decorative procedure makes it undesirable for most women. The pigment is applied using a motorized instrument with a single or multiple sterilized needles often performed in repeated sessions. Practitioners who apply these tattoos are physicians, other medical personnel, or lay tattoo artists depending on state law or local ordinances. There is no federal legislation that regulates tattooing.39Practitioners, depending on their qualifications and expertise, use ice packs, topical anesthetics such as a eutectic mixture of lidocaine and prilocaine (EMLA cream), injected local anesthetic, or a regional block of the second and third branches of the trigeminal nerve to mitigate any discomfort or pain.45Anesthetic injected into the vermilion border has drawbacks because it causes distortion and hematomas in some cases. The manufacturers of pigments for tattooing consider their composition proprietary information. The FDA does not inspect or regulate tattoo pigment manufacturers and has not established comprehensive safety standards for intradermal use of pigments. In 1976, the FDA limited the concentration of mercury to 3 parts per billion in these pigments, eliminating the use of cinnabar in the United States, but it still may be used in other nations, and lip micropigmentation is practiced around the world.
ADVERSE REACTIONS
Lip Tattooing (Micropigmentation) Micropigmentation In marked contrast to lipstick that colors the lips for hours, micropigmentation colors the lips for years, although there is some fading with time. Lip tattooing is used to define the lip margins with color similar to a lip liner or, less frequently, to color the entire vermilion border. This procedure can help correct the appearance of thin, asymmetric, scarred, or dropping lips. It benefits patients
Lip tattooing can trigger an episode of recurrent herpes labialis, and medical practitioners frequently administer oral antiviral drugs, such as acyclovir, prophylactically to prevent this. Tattooing, unless performed under universal precautions with scrupulous sterile technique including sonic cleaning and autoclaving of the instruments, carries a risk
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of transmitting infectious diseases, including viral hepatitis and human immunodeficiency virus (HIV) infection.39 Granulomatous foreign body, allergic, and photoallergic reactions have been reported from tattooing. Mercury accounted for most of the allergic reactions to red tattoos, but in the United States, its restriction has ameliorated this. Tattoo pigments may contain other metal pigments, including iron oxides, titanium, silicon, cadmium, and aluminum. The traditional red organic dyes are sandalwood, brazilwood, and carmine from dried insect bodies. Lip micropigments are proprietary mixtures that may contain organic FD&C dyes. Allergic reactions to red skin tattoos are infrequent but well recognized, so that reactions to lip micropigmentation are to be expected and are quite troublesome. The few reported reactions are protracted and respond only partially to topical and intradermal corticosteroids, and this therapy carries a risk of atrophy.40Laser destruction of tattoos on the lip presents a difficult problem because of the risk of scarring in this cosmetically important location." Q-switched lasers have darkened the pigment of iron oxide by reducing it from ferric to ferrous oxide. Carbon dioxide laser ablation has been proposed for removal of lip tattoos, but a series of cases has not been published to document its success." In some cases of a delayed-type allergic reaction to tattoo pigment, patch testing can detect the allergen. If these results are negative, intradermal testing with the individual pigments may be required to determine the responsible agent.25
Cheilitis and Lip Cosmetics Most reported adverse reactions caused by lip cosmetics are of the delayed allergic contact type. They appear on the external surface of the lips, generally sparing the mucous membrane inside the mouth. They are manifest as erythema, scaling, and swelling and may lead to blistering and occasionally hyperpigmentation. The cheilitis may not extend beyond the vermilion border and may spare the angle of the mouth. The vermilion border does not produce a stratum corneum that is the major barrier to percutaneous ab-
sorption. Ophaswongse and MaibachZ7have hypothesized that absorption of materials applied directly to the vermilion border would be high, but clinical data to establish that this is the case have not been published. Contact dermatitis caused by lipstick may spread beyond the lips onto the face as it worsens. Some women use lipstick to rouge their cheeks, and this habit can lead to the appearance of lipstick contact dermatitis in unexpected areas on the A detailed history of each patient's makeup routine can be helpful in these cases. Lipstick seldom has been reported to cause irritant contact dermatitis or contact urticaria, but this may represent a lack of recognition on the part of clinicians. In one case, repeated episodes of burning and itching of the lips after application of a lipstick led to hyperpigmentation. Patch testing was negative, and the authors suggested a diagnosis of irritant contact dermatitis.19 The largest published review of cheilitis comes from Australia; 75 cases referred to a tertiary contact dermatitis clinic were analyzed, and one quarter were due to allergic contact dermatiti~.'~ Four cases were caused by the ingredients in lipstick, and three cases were caused by sunscreening lip balms; in total, these products accounted for nearly 10% of the cases of cheilitis. In a review of 27 consecutive patients with cheilitis from Singapore, one third of the patients had allergic contact dermatitis; four cases were attributed to lipsticks, although in 2 patients, it was believed that the nickel in the lipstick case played a In patients with puzzling cheilitis, patch testing plays an important role in determining the diagnosis. Lipstick and most lip cosmetics can be patch tested as is. In addition to a standard tray, personal care products, oral hygiene products, UV filters, and a cosmetic series should be included in the testingz7
Allergens in Lip Cosmetics Ophaswongse and Maibachz7reviewed reports of allergy to lipstick ingredients thoroughly to 1994, and de Groot et a17 provided further information on concentrations of these ingredients for patch testing.
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Colors
Antioxidants
Before the 1960s, lipstick allergy was the most common type of cosmetic allergy. Eosin was the bromofluorescein dye used in the then popular indelible lipsticks that actually stained the lips. A chemical contaminant in eosin caused most of the reactions? Now eosin is purified better, and indelible ingredients are no longer popular so that these reactions have all but vanished. Eosin was present at the 1%to 2% level in indelible lipsticks, but patch testing was carried out with 50% in petrolatum to overcome this dye's strong bonding to the keratin layer. Carmine red, which is the aluminum lake of the pigment cochineal derived from the bodies of insects, was reported as an allergen in lip salve.= D&C Yellow No. 11 was reported in three cases of lipstick dermatitis in 1976, but that dye is no longer permitted for use in lipstick in the United state^.^ Many colorants, some of which were allergens, such as D&C Red No. 9,38are no longer permitted in lipsticks in the United States for other reasons. In the 1970s and 1980s, colorants were screened extensively by the Ames test, and D&C Orange No. 17 was mutagenic without microsomal activation.18 Animal feeding and painting tests were carried out, and in one test of D&C Red No. 9, there were increased splenic sarcomas and liver neoplasms in rats.21The safety of D&C Red No. 8, D&C Red No. 9, D&C Red No. 19, and D& C Orange No. 17 was debated for years, but the FDA permanently listed them for use in cosmetics. A consumer advocacy group successfully challenged the action in the U.S. courts, and as of July 15, 1988, it became illegal to use these four colors in cosmetics sold in the United States.12
Butylhydroxyanisole, tertiary butylhydroquinone, and butylhydroxytoluene all have been reported as allergens in lipsticks,& as have octyl, dodecyl, and propyl gall ate^.^, 35
Waxes Microcrystalline wax in a lip salve caused allergic contact dermatitis in three consumers; this may be patch tested as is or 10% in petrolatum.8 Emollients Castor oil, ricinoleic acid, and lanolins commonly are present in lipsticks and have accounted for allergic cheilitis.',
Flavorings and Fragrances Vanilla in a lip salve caused a recurrent dermatitis in a 13-year-old girl, illustrating that cheilitis in children may be related to lip
PROTECTI0 N
It is generally assumed that lip cosmetics, in addition to beautifying the lips, can protect them from adverse environmental conditions. These environmental factors include irritation from saliva, low humidity, wind, cold temperature, and UV light exposure. The lips, exposed chronically to UV light, cannot respond as the skin does with the self-protective mechanisms of tanning and hypertrophy of the stratum corneum. It is important that physicians recommend lip cosmetics with sunscreening agents to prevent recurrent herpes labialis, photoaging, and lip cancer. Early studies have shown that lip balms cannot be assumed to provide effective protection in rigorous conditions. In 1981, standard army issue sunscreening lipsticks for hot and cold weather were tested for protection from four minimal erythema doses (MEDs) with a xenon solar simulator in rabbits.23 These products afforded no significant protection. The authors had used off-the-shelf products and were concerned that these sticks may have deteriorated from age or improper storage. In 1983, Shulman and studied soldiers on desert maneuvers where the average temperature was 37°C centigrade and the relative humidity was 29.5%. These oral pathologists examined 1053 of the 2500 participating soldiers for signs of chapped lips during the third week of this desert training program. Lip chapping was classified as severe if there was cracking, crusting, or bleeding of the vermilion border and classified as moderate if scaling, desquamation, and dryness were noted. One third of the soldiers
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were noted to have chapped lips-in 10% ( n = 150), chapping was severe, and in 23.5% ( n = 247), it was moderate. The soldiers had been issued a lip protectant stick with p-aminobenzoic acid (otherwise not characterized) and were interviewed regarding its use at the time of examination. The data showed no correlation between the use of the lip protectant and avoidance of chapping. The study is flawed because the soldiers may have answered in the affirmative believing compliance would put them in a favorable light with their superior officers, frequency and method of use were not evaluated, and the composition of the stick was not revealed. In both these studies, the army issue products did not bear a SPF number, which is an important guide for the consumer buying commercial products. the In the study by Shulman and soldiers that used the lip protectant with sunscreen had a reduction in the incidence of recurrent herpes labialis. Laboratory studies can provide stronger evidence that application of sunscreening agents to the lips can prevent UV light-induced recurrent herpes labialis. Rooney et a133 studied 38 patients with a history of recurrent herpes labialis. These subjects were given four MEDs of UV light to a site on their lips where they had experienced herpes labialis on two occasions. A commercially available SPF 15 sunscreening lotion was applied before the radiation on one of the occasions and a placebo lotion on the other. Twenty seven of the 38 (71%) experienced a recurrence of herpes labialis when the placebo was used, and none of the subjects experienced a clinical recurrence when the sunscreen was applied. One subject using the sunscreen showed viral shedding of herpes simplex type 1. This protective effect is more difficult to show outside the laboratory when the radiation is less intense. In a study of 51 skiers with histories of skiing triggering herpes labialis, there was only a 12% recurrence rate during 1 week of skiing, and no protective effect of frequent sunscreen use could be shown.26It is estimated that 150 million Americans have latent herpes simplex virus type 1 infection and that there are 100 million episodes of recurrence each year.33 In light of the experimental evidence, coupled with
patients' anecdotal experience, most dermatologists recommend conscientious use of lip sunscreens for patients with a history of recurrent herpes labialis. An epidemiologic study explored whether the recognized dramatically lower incidence of lip cancer in women compared with men even after tobacco use is accounted for may be partially attributed to the UV light protective effect of lip cosmetics.30Comparing the female subjects with lip cancer with a control group of women, those with high lifetime solar radiation exposure who used lip protection only once daily or less often had twice the risk of lip cancer. Colored lipstick without added sunscreening chemicals was counted among the lip-covering protectants. This study suggests that sun exposure plays a causative role for lip cancer and that use of lip cosmetics can reduce that risk. The use of lip sunscreens for men and women appears to prevent actinic damage of the vermilion border, and for women, colored lipsticks seem to offer some benefits, although this undoubtedly varies with the pigment content and frequency of application.
BEAUTlFlCATlON Physicians should not underestimate the importance of cosmetics for decoration and correction. In one study, two women who suffered postoperative facial nerve palsy were taught corrective makeup techniques, including using lipstick to correct asymmetry of their mouths.22The results of personality assessment testing administered before and after instructions showed positive findings, including reduction in depression and feelings of inferiority. Draelos'O has discussed the use of lip cosmetics to improve the appearance of elderly women by camouflaging lentigines, venous lakes, and actinic cheilitis with densely pigmented lipsticks. She has illustrated artfully how to correct asymmetry or change the appearance of the size of the lips with lip liner and a matte finish lipstick. Many patients would benefit from a discussion of the use of lip and other cosmetics to improve their appearance and their spirits.
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References 1. Andersen KE, Nelsen R: Lipstick dermatitis related to castor oil. Contact Dermat 11:253, 1984 2. Arquette J, Cummings M, Reinhart J: Jojoba esters in lipsticks. Cosmetics Toiletries 113:63, 1998 3. Baran R, Chivot M, Shalita A R Acne. In Baran R, Maibach HI (eds): Textbook of Cosmetic Dermatology, ed 2. London, Martin Dunitz, 1998, p 431 4. Calnan CD: Allergic sensitivity to eosin. Acta Allerg 13:493, 1959 5. Calnan CD: Quinazoline Yellow SS in cosmetics. Contact Dermat 2:160, 1976 6. Cronin E (ed): Cosmetics. In Contact Dermatitis. London, Churchill Livingstone, 1980 7. de Groot AC, Weyland JW, Nater JP (eds): Face cosmetics. In Unwanted Effects of Cosmetics and Drugs Used in Dermatology, ed 3. New York, Elsevier, 1994, p 498 8. de Darko E, Osmundsen PE: Allergic contact dermatitis to Lipcare lipstick. Contact Dermat 11:46, 1984 9. Downs AMR, Lear JT, Sansom JE: Contact sensitivity in patients with oral symptoms. Contact Dermat 39258, 1998 10. Draelos ZD (ed): Lip cosmetics. In Cosmetics in Dermatology, ed 2. New York, Churchill Livingstone, 1995 11. Duke D, Urioste SS, Dover JS, et al: A reaction to a red lip cosmetic tattoo. J Am Acad Dermatol 39:488, 1998 12. Faulkner EB: Formulating decorative cosmetics with certifiable colors: Past, present and future. Cosmetics Toiletries 10429, 1989 13. Fed Reg 48(32) Feb. 15, 1983, p 5 14. Ferguson JE, Beck MH: Contact sensitivity to vanilla in a lip salve. Contact Dermat 33:352, 1995 15. Freeman S, Stephens R: Cheilitis: Analysis of 75 cases referred to a contact dermatitis clinic. Am J Contact Dermat 10:198, 1999 16. Fox C: Color in cosmetics. Cosmetics Toiletries 111:35, 1996 17. Gray H: Anatomy, Descriptive and Surgical: A Revised American, from the Fifteenth English, Edition. New York, Bounty Books, 1977, pp 869-870 18. Green MR, Pastewka JV:Mutagenicity of some lipsticks and their dves. T Natl Cancer Inst 64:665, 1980 19. Hemmer W, Fock;! M,-Gotz M, et al: Pigmented contact dermatitis of the lips from a lipstick. Contact Dermat 37244, 1999 20. Hoffmann C, Schuller-Petrovic S, Soyer P, et al: Adverse reactions after cosmetic lip augmentation with permanent biologically inert implant materials. J Am Acad Dermatol40:100, 1999 21. IARC Monogr Eva1 Carcinog Risks Hum 57203,1993 22. Kanzaki J, Ohshiro K, Abe T: Effect of corrective make-up training on patients with facial nerve paralysis. Ear Nose Throat J 77270, 1998 23. Kessler HP, Webb JG: An evaluation of actinic blocking agents. Milit Med 146339, 1981 24. Lim JTE, Ng SK, Goh C L Contact cheilitis in Singapore. Contact Dermat 27263, 1992
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25. McFadden N, Lyberg T, Hensten-Pettersen A: Aluminum-induced granulomas in a tattoo. J Am Acad Dermatol 20:903, 1989 26. Mills J, Hauer L, Gottlieb A, et al: Recurrent herpes labialis in skiers: Clinical observations and effect of sunscreen. Am J Sports Med 15:76, 1987 27. Ophaswongse S, Maibach H I Allergic contact cheilitis. Contact Dermat 33:365, 1995 28. Otterstatter G: Coloring cosmetics. Cosmetics Toiletries 111:25, 1996 29. Payne TF: An evaluation of actinic blocking agents for the protection of the lip mucosa. J Am Dent Assoc 92:409, 1976 30. Pogoda JM, Preston-Martin S: Solar radiation, lip protection and lip cancer in Los Angeles County women (California, United States). Cancer Causes Control 7458, 1996 31. Romanowski P, Schueller R Creating colorful cosmetics: An introduction to colorants in the personalcare industry. Cosmetics Toiletries 112:73, 1997 32. Romm S On the beauty of lips. Clin l'last Surg 11:571, 1984 33. Rooney JF, Bryson Y, Mannix ML, et al: Prevention of ultraviolet-light-induced herpes labialis by sunscreen. Lancet 338:1419, 1991 34. Sarkany I, Meara RH, Everall J: Cheilitis due to carmine in lip salve. Transactions of the St. John's Hospital Dermatological Society 46:68, 1961 35. Serra-Baldrich E, Puig LL, Arnau AG, et al: Lipstick allergic contact dermatitis from gallates. Contact Dermat 32:359, 1995 36. Shellev WB. Shellev ED: Chaustick acne. Cutis 37459,'1986 37. Shulman JD,Lewis DL: The prevalence of chapped lips during an army hot weather exercise. Milit Med 162:817, 1997 38. Sugai T, Takahashi Y, Takagi T Pigmented cosmetic dermatitis and coal tar dyes. Contact Dermat 3:249, 1977 39. Tope WD, Phil M: State and territorial regulation of tattooing in the United States. J Am Acad Dermatol 32:791, 1995 40. Tresukosol R, Ophaswongse S, Kullavanijava P: Cutaneous reaction to cosmetic lip tattooing. Contact Dermat 36:176, 1997 41. Wall FE: Historical development of the cosmetic industry. In Balsam MS, Sagarin E (eds): Cosmetics: Science and Technology, ed 2. New York, John Wiley & Sons, 1974 42. Wang T-S, Lee G: The effect of formulation on the hardness and crystallization of emulsion lipsticks. J SOCCosmet Chem 48:41, 1997 43. Wenninger JA, McEwen GN (eds): International Cosmetic Ingredient Handbook, ed 3. Washington, DC, The Cosmetic, Toiletry, and Fragrance Association, 1995 44. White IR, Love11 CR, Cronin E: Antioxidants in cosmetics. Contact Dermat 11:265, 1984 45. Zwerling CS, Walker AC, Goldstein NF: Lip pigmentation techniques. In Micropigmentation, State of the Art. Goldsboro, NC, Zwerling, 1993
Address reprint requests to Patricia G. Engasser, MD 34 Ashfield Road Atherton, CA 94027 e-mail: [email protected]
0733-8635100 $15.00
+ .OO
LIP COSMETICS Patricia G. Engasser, MD
”The lips are two fleshy folds which surround the orifice of the mouth, formed externally by integument and internally by mucous membrane, between which are found the Orbicularis oris muscle, coronary vessels, nerves, areolar tissue, and fat and numerous small labial glands.”17This anatomic description of human lips appeared at the beginning of the twentieth century. In the new millennium, it is understood that lips are much more than the sum of their parts.
HISTORY
Through the centuries, the beauty of the lips has been extolled by poets and painters. Red, full, moist, relaxed, slightly parted lips are considered sensuous. People in primitive cultures have stretched lips to gigantic proportions by inserting wooden disks; in more advanced developed countries, people plump the lips up by implanting bovine collagen and Gore-Tex threads.20Egyptian and Assyrian women painted their lips with plant material thousands of years ago. In the eighteenth century, Japanese women painted rouge on their mouth in a classic ochoboguchi style to express innocence, and contemporary Japanese brides continue this custom.32Rouging lips alternatively has been indulged or
scorned by societies. Following the Victorian era in 1915, its popularity grew again, and Levy persuaded the Scovill Manufacturing Company to produce lip rouge in a handy stick that was sold in a push-up case.41Lipstick was created, and the swivel case soon followed. In 1919, the Morton Manufacturing Company, in Lynchburg, VA, began the manufacture of Chap Stick, a lip balm to treat dryness and peeling. By 1946, American women spent around $30 million yearly for 5000 tons of lipstick that was available in a wide array of shades.32 In the 1950s, Revlon first rhapsodized their shades with romantic titles such as Fire and Ice and Cherries in the Snow, dramatizing this in elaborate, color, pictorial advertisements in women’s magazines. Fashion is fickle, and pale lip colors prevailed in the early 1970s, but women continued to apply lipstick. In the 1990s, dazzling colors created with newer pigment technology boost the sales of these ever-popular cosmetics. Lipstick‘s appeal extends to women of all ages; it frequently is the first cosmetic used by adolescents, and elderly women apply it daily. Many women do not feel dressed without it. Recovering patients apply lipstick because they feel better, and their appearance with the lipstick gives them a psychologic boost. Most women in the United States present a face to the world that has colored lips.
From the Department of Dermatology, Stanford University School of Medicine, Stanford; and the Department of Dermatology, University of California San Francisco School of Medicine, San Francisco, California
DERMATOLOGIC CLINICS
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VOLUME 18 NUMBER 4 OCTOBER 2000
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CATEGORIES
Lipsticks Lipsticks are cosmetics applied to the vermilion border to impart color and to define shape as well as provide protection from environmental conditions. They commonly are solid mixtures of lipids that soften at body temperature for smooth application-they are designated as thermoplastic for this reason. In addition to the visual characteristics they impart, consumers expect these cosmetics to give a pleasant, smooth feeling to this area of mucous membrane, which becomes dry and peels easily. Lipsticks are left on the lips (75 to 300 mg per application) and must be safe to ingest. They should not have an unpleasant taste or odor. Lipsticks are composed of five categories of ingredients-waxes, emollients, marketing and functional ingredients, stabilizers, and colorants. Waxes Waxes give structure to lipsticks, and because no single wax provides ideal texture, heat stability, and application and wear characteristics, mixtures are used. The blends of waxes can be plant derived, such as carnauba, candelilla, and rice bran, or petroleum derived, such as paraffin, ceresin, microcrystalline wax, and polyethylene.
lar to the action of surfactants for an oil and water solution, but oleyl alcohol has a double bond, making it more susceptible to oxidation and rancidity. Fatty esters, such as octyl palmitate, increase slip and impart a lighter feel. By balancing the amounts of wax and emollients, the creator of a lipstick can determine if the cosmetic is one that is firm and resists feathering-a term used to describe the creeping of color up the fine lines around the mouth. Lipsticks with a high emollient content impart a lubricious feel and give a moist appearance that is considered alluring, but they do not stay on the lips as well. Longwearing lipsticks have higher wax content in relation to emollients to allow longer pigment deposition, but they feel drier to the consumer and are less glossy.* Silicones are a special class of polymers that have become popular additions to lipsticks in the 1990s. They are inert, inexpensive, and colorless, and some are volatile. Dimethicone imparts barrier properties and, when present at 1% concentration, can allow an antichapping claim to be made. Volatile silicones (e.g., cyclomethicone and low-molecular-weight dimethicones) act as oils on application. As the lipstick sets, these silicones evaporate, and the remaining pigments resist transfer to cups, glasses, and kissed cheeks. Transferresistant lipsticks have a matte or dry finish and do not have a lubricious gloss. They are generally sold in slender cases that snap shut to prevent evaporation.
Emollients Emollients plasticize the waxes. In addition to providing moisturization and emolliency for the lips, they modify the application characteristics of slip, tack, and drag. A critical balance of these characteristics in the product must be achieved for a desired esthetic result on the lips. Emollients impart gloss and allow pigment wetting and dispersion. Popular natural emollients include castor oil, jojoba oil, and lanolin derivatives. Synthetic esters, polymers for film forming, and hydrocarbons are other important components. Isostearyl alcohol is a liquid with a low melting point that wets pigments, allowing their dispersions in this lipid mixture. Oleyl alcohol wets pigments and acts as a coupling agent, which allows the combination of different oils simi-
Miscellaneous Enhancing Ingredients Miscellaneous enhancing ingredients include materials that add function or marketing appeal. For example, menthol or camphor is added to impart a cool sensation on application and to give the impression of active ingredients. Lipsticks are regulated as overthe-counter drugs when chemical or physical sunscreens are added, and they are labeled with a sun protection factor (SPF). Ordinary lipstick pigments generally do not provide more than a SPF 4 protection (R. Sandewicz, personal communication). The popularity of vitamins, antioxidants, and botanicals has led to their appearance in lipsticks. Flavoring agents are added, especially to lip salves, that appeal to younger consumers
LIP COSMETICS
as a selling point. Fragrance mixtures are common ingredients. In lipid preparations, masking agents are used to cover unpleasant odors (e.g., ethylene brassilate, mint, or menthol). Stabilizers
The shelf life of a lipstick is generally 2 to 5 years. Lipsticks usually are anhydrous and easier to preserve from bacterial contamination than formulations made with water. Emulsion lipsticks can be formulated to create a more emollient product, but they are uncommon.42Antimicrobials commonly used in lipsticks are the parabens and phenoxyethanol. These products often are preserved with antioxidants, such as butylhydroxyanisole (BHA) or one of the gallates, particularly when unsaturated lipids are present. Colorants
Market research has established that the most important reason for a consumer to purchase a lipstick is its color appeal. The range of colors is astonishing considering the pallet of the cosmetic chemist has been significantly diminished in the last 4 decades. In 1959, there were 116 certifiable colors approved for use in cosmetics in the United States, and that number has been reduced to 34 at present.31 Until the twentieth century, there was little regulation of the safety of colors added to foods, drugs, and cosmetics, with some deaths resulting. The 1938 Food, Drug, and Cosmetic Act required that each batch of organic colorants must be confirmed as conforming to established standards to be certified. The 1960 Color Additive Amendments allowed the Food and Drug Administration (FDA) to set limitations on the amounts of color used. The manufacturers were required to submit data on the safety of the colorants. Colorants are either organic or inorganic; approved inorganic colorants, such as titanium dioxide (Ti02) or iron oxides, do not require batch certification. In the United States, approved organic colors are designated for Food, Drug and Cosmetic (FD&C) or Drug and Cosmetic (D&C)groups, both of which may be used on mucous membranes or ingested, but the External Drug and Cosmetic
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(Ext. D&C) group cannot be allowed on mucous membranes or ingested and is unsuitable for lip cosmetics (Table 1). The European Community and the Japanese lists of approved colors differ in many respects from those of the United States. The Europeans have a larger number of approved colors and employ the Color Index number for identification.28 For lipsticks, insoluble pigments or lakes are used for coloring. Lakes are pseudopigments produced by precipitating water-soluble colorants with water-insoluble salts, such as aluminum hydroxide. Lakes are virtually insoluble, and they can be handled as pigments. Formerly the indelible lipsticks used bromo colors, such as eosin (D&C Red No. 21), but they left a cherry red color on the lips and are unpopular at present. Sophisticated complex colors are used in many modern lipsticks. The use of pearlized colors has brought dramatic changes. They produce reflectance similar to tiny mirrors or interference depending on the coating thickness for Ti02/ mica. Powders, such as organically modified clays, silica, mica, or polymethyl methacrylate, also absorb oils, reduce bleeding of colors, and can enhance the tactile sensation. Producing uniformly colored, esthetic lipsticks, which are stable under extreme environmental conditions, requires the talents and knowledge of an experienced cosmetic chemist. Lipsticks are heated during manufacture to 5" above the highest melting point of the waxes, the milled pigments are mixed in, and the batch is poured into molds. The molded
Table 1. COLORING AGENTS FOR LIP COSMETICS Certified
D&C Orange No. 5 D&C Red No. 6 D&C Red No. 7 D&C Red No. 21 D&C Red No. 22 D&C Red No. 27 D&C Red No. 28 D&C Red No. 30 D&C Red No. 33 D&C Red No. 36 D&C Yellow No. 10 FD&C Blue No. 1 FD&C Yellow No. 5 FD&C Yellow No. 6
Certification Not Required
Titanium dioxide Mica Zinc oxide Iron oxides Carmine Bismuth oxychloride Bronze powder Ultramarines
Dntafrom references 28 and 43.
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lipsticks are passed through a gas flame to create a smooth, shining surface for eye appeal. Lipsticks vary in functional characteristics depending on their composition (Table 2). Oils give slip, a lighter feel, more gloss, and a tendency for colors to bleed. Waxes add to the tack and drag, resulting in longer wear, less bleeding, and diminished gloss. Lip Liners. Lip liners are modified lipsticks used to define the outline of the lips and to deposit a high pigment content that is not mobile. These commonly are sold as pencils that can be sharpened, but they can be made in thin swivel containers. Lip liners are effective when the natural lip contour is being modified or corrective makeup is being applied. Using lip liners decreases the feathering of lipstick into the lines around aging lips. Lip Glosses. Lip glosses have little wax and high oil content and are not in molded sticks. These are sold in pots or containers with a wand for application. They have low color content and make the lips shine. Some of these are marketed to young consumers and are heavily fragranced and flavored with fruit flavoring. Glosses do not stay on the lips well and migrate into the lip lines in mature women. Liquid Lipsticks. Liquid lipsticks usually are anhydrous with less wax than conventional lipsticks. Similar to lip glosses, they are not molded into sticks, but liquid lipsticks contain a high pigment content that appears more transparent. They can be transfer resistant.
Lip Balms A lip balm is an over-the-counter drug defined as ”a drug product that relieves and
prevents dryness or chapping of the exposed surface of the lip.”I3 The vermilion border is devoid of sebaceous or salivary gland and dries easily. Chapping is a reaction to environmental conditions, especially to cold or hot dry winds. The keratin of the vermilion border becomes inflexible or brittle, then cracks and peels. Subjects may lick their lips or pick at the flakes, aggravating the condition. Lip balms provide a barrier of protection. To qualify as a lip balm, a product must contain one of the following: Allantoin, 0.5% to 2% Aluminum hydroxide gel, 0.15% to 5% Calamine, 1%to 25% Cocoa butter, 50% Dimethicone, 1%to 30% Glycerin, 20% to 45% Kaolin, 4% to 20% Petrolatum, 30% to 100% Shark liver oil, 3% White petrolatum, 30% to 100% Zinc acetate, 0.1% to 2% Zinc carbonate, 0.2% to 2% Zinc oxide, 1%to 25% Some of these ingredients could raise concerns about comedogenicity and exacerbating perioral comedones in patients with acne.36 Dermatologists find these products useful for treating the lip chapping that often accompanies oral retinoid the rap^.^
Lip Sunscreens Chemical sunscreening ingredients are added to a colorless lipstick or lip balm to attain usually an SPF of 8 or greater. Colored lipsticks also are incorporating sunscreening agents. Once the SPF claim is made, these lipsticks are regulated as over-the-counter drugs as well as cosmetics. Ordinary effective sunscreens for glabrous skin are less effective
Table 2. LIPSTICK FORMULATIONS Ingredients
Waxes Volatiles Oils/ semisolids Colors and uowders
Lip Gloss Creamy Lipstick Long-Wearing Lipstick Transfer-Proof Lipstick Lip Liner
3-8% None 70-8OYo 0-5%
10-15% None 60-70% 10-15%
15-20% None 50-6OYo 10-15%
10-15’Xo 35-40% lo-20% 10-20%
1525% Varies 40-50% 1525%
Adapted from Sandewicz R W Lip and nail product technology continuing education course, for the Society of Cosmetic Chemists, December 8, 1999; with permission.
LIP COSMETICS
for the lips because lip sunscreens must have unique properties of adherence that resist friction and licking
Lipstick Primers Lipstick primers, which come in stick or cream form, act as a foundation for lipstick to help it adhere and to fill in the fine creases around the mouth. They allow a smoother application of lipstick. Some women apply liquid facial makeup as foundation to prepare the lips.
Lipstick Overcoats Lipstick overcoats are applied over lipstick to prevent it from coming off. They may contain perfluoro compounds and powder of polymethyl methacrylate.I6
Lip Treatment Products An array of specialty lip cosmetics are being introduced that are similar to products used for facial skin care. Lip masks may incorporate exfoliating ingredients, and lip makeup cleansers ease removal of lipstick to avoid soiling bathroom linens. The real expansion has been in products that incorporate retinoids, alpha hydroxy acids, vitamins E and C, and other antioxidants, modeling themselves on the cosmeceuticals designed for other areas of the facial skin. There does not appear to be published documentation of their efficacy for the lip area.
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whose vision or motor skills are impaired so that they are unable to apply lipstick correctly. Some consumers choose lip tattooing because they want color that will not migrate into wrinkles, or they wish to avoid the bother of applying lipstick frequently. Because fashion changes constantly, the permanency of this decorative procedure makes it undesirable for most women. The pigment is applied using a motorized instrument with a single or multiple sterilized needles often performed in repeated sessions. Practitioners who apply these tattoos are physicians, other medical personnel, or lay tattoo artists depending on state law or local ordinances. There is no federal legislation that regulates tattooing.39Practitioners, depending on their qualifications and expertise, use ice packs, topical anesthetics such as a eutectic mixture of lidocaine and prilocaine (EMLA cream), injected local anesthetic, or a regional block of the second and third branches of the trigeminal nerve to mitigate any discomfort or pain.45Anesthetic injected into the vermilion border has drawbacks because it causes distortion and hematomas in some cases. The manufacturers of pigments for tattooing consider their composition proprietary information. The FDA does not inspect or regulate tattoo pigment manufacturers and has not established comprehensive safety standards for intradermal use of pigments. In 1976, the FDA limited the concentration of mercury to 3 parts per billion in these pigments, eliminating the use of cinnabar in the United States, but it still may be used in other nations, and lip micropigmentation is practiced around the world.
ADVERSE REACTIONS
Lip Tattooing (Micropigmentation) Micropigmentation In marked contrast to lipstick that colors the lips for hours, micropigmentation colors the lips for years, although there is some fading with time. Lip tattooing is used to define the lip margins with color similar to a lip liner or, less frequently, to color the entire vermilion border. This procedure can help correct the appearance of thin, asymmetric, scarred, or dropping lips. It benefits patients
Lip tattooing can trigger an episode of recurrent herpes labialis, and medical practitioners frequently administer oral antiviral drugs, such as acyclovir, prophylactically to prevent this. Tattooing, unless performed under universal precautions with scrupulous sterile technique including sonic cleaning and autoclaving of the instruments, carries a risk
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of transmitting infectious diseases, including viral hepatitis and human immunodeficiency virus (HIV) infection.39 Granulomatous foreign body, allergic, and photoallergic reactions have been reported from tattooing. Mercury accounted for most of the allergic reactions to red tattoos, but in the United States, its restriction has ameliorated this. Tattoo pigments may contain other metal pigments, including iron oxides, titanium, silicon, cadmium, and aluminum. The traditional red organic dyes are sandalwood, brazilwood, and carmine from dried insect bodies. Lip micropigments are proprietary mixtures that may contain organic FD&C dyes. Allergic reactions to red skin tattoos are infrequent but well recognized, so that reactions to lip micropigmentation are to be expected and are quite troublesome. The few reported reactions are protracted and respond only partially to topical and intradermal corticosteroids, and this therapy carries a risk of atrophy.40Laser destruction of tattoos on the lip presents a difficult problem because of the risk of scarring in this cosmetically important location." Q-switched lasers have darkened the pigment of iron oxide by reducing it from ferric to ferrous oxide. Carbon dioxide laser ablation has been proposed for removal of lip tattoos, but a series of cases has not been published to document its success." In some cases of a delayed-type allergic reaction to tattoo pigment, patch testing can detect the allergen. If these results are negative, intradermal testing with the individual pigments may be required to determine the responsible agent.25
Cheilitis and Lip Cosmetics Most reported adverse reactions caused by lip cosmetics are of the delayed allergic contact type. They appear on the external surface of the lips, generally sparing the mucous membrane inside the mouth. They are manifest as erythema, scaling, and swelling and may lead to blistering and occasionally hyperpigmentation. The cheilitis may not extend beyond the vermilion border and may spare the angle of the mouth. The vermilion border does not produce a stratum corneum that is the major barrier to percutaneous ab-
sorption. Ophaswongse and MaibachZ7have hypothesized that absorption of materials applied directly to the vermilion border would be high, but clinical data to establish that this is the case have not been published. Contact dermatitis caused by lipstick may spread beyond the lips onto the face as it worsens. Some women use lipstick to rouge their cheeks, and this habit can lead to the appearance of lipstick contact dermatitis in unexpected areas on the A detailed history of each patient's makeup routine can be helpful in these cases. Lipstick seldom has been reported to cause irritant contact dermatitis or contact urticaria, but this may represent a lack of recognition on the part of clinicians. In one case, repeated episodes of burning and itching of the lips after application of a lipstick led to hyperpigmentation. Patch testing was negative, and the authors suggested a diagnosis of irritant contact dermatitis.19 The largest published review of cheilitis comes from Australia; 75 cases referred to a tertiary contact dermatitis clinic were analyzed, and one quarter were due to allergic contact dermatiti~.'~ Four cases were caused by the ingredients in lipstick, and three cases were caused by sunscreening lip balms; in total, these products accounted for nearly 10% of the cases of cheilitis. In a review of 27 consecutive patients with cheilitis from Singapore, one third of the patients had allergic contact dermatitis; four cases were attributed to lipsticks, although in 2 patients, it was believed that the nickel in the lipstick case played a In patients with puzzling cheilitis, patch testing plays an important role in determining the diagnosis. Lipstick and most lip cosmetics can be patch tested as is. In addition to a standard tray, personal care products, oral hygiene products, UV filters, and a cosmetic series should be included in the testingz7
Allergens in Lip Cosmetics Ophaswongse and Maibachz7reviewed reports of allergy to lipstick ingredients thoroughly to 1994, and de Groot et a17 provided further information on concentrations of these ingredients for patch testing.
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Colors
Antioxidants
Before the 1960s, lipstick allergy was the most common type of cosmetic allergy. Eosin was the bromofluorescein dye used in the then popular indelible lipsticks that actually stained the lips. A chemical contaminant in eosin caused most of the reactions? Now eosin is purified better, and indelible ingredients are no longer popular so that these reactions have all but vanished. Eosin was present at the 1%to 2% level in indelible lipsticks, but patch testing was carried out with 50% in petrolatum to overcome this dye's strong bonding to the keratin layer. Carmine red, which is the aluminum lake of the pigment cochineal derived from the bodies of insects, was reported as an allergen in lip salve.= D&C Yellow No. 11 was reported in three cases of lipstick dermatitis in 1976, but that dye is no longer permitted for use in lipstick in the United state^.^ Many colorants, some of which were allergens, such as D&C Red No. 9,38are no longer permitted in lipsticks in the United States for other reasons. In the 1970s and 1980s, colorants were screened extensively by the Ames test, and D&C Orange No. 17 was mutagenic without microsomal activation.18 Animal feeding and painting tests were carried out, and in one test of D&C Red No. 9, there were increased splenic sarcomas and liver neoplasms in rats.21The safety of D&C Red No. 8, D&C Red No. 9, D&C Red No. 19, and D& C Orange No. 17 was debated for years, but the FDA permanently listed them for use in cosmetics. A consumer advocacy group successfully challenged the action in the U.S. courts, and as of July 15, 1988, it became illegal to use these four colors in cosmetics sold in the United States.12
Butylhydroxyanisole, tertiary butylhydroquinone, and butylhydroxytoluene all have been reported as allergens in lipsticks,& as have octyl, dodecyl, and propyl gall ate^.^, 35
Waxes Microcrystalline wax in a lip salve caused allergic contact dermatitis in three consumers; this may be patch tested as is or 10% in petrolatum.8 Emollients Castor oil, ricinoleic acid, and lanolins commonly are present in lipsticks and have accounted for allergic cheilitis.',
Flavorings and Fragrances Vanilla in a lip salve caused a recurrent dermatitis in a 13-year-old girl, illustrating that cheilitis in children may be related to lip
PROTECTI0 N
It is generally assumed that lip cosmetics, in addition to beautifying the lips, can protect them from adverse environmental conditions. These environmental factors include irritation from saliva, low humidity, wind, cold temperature, and UV light exposure. The lips, exposed chronically to UV light, cannot respond as the skin does with the self-protective mechanisms of tanning and hypertrophy of the stratum corneum. It is important that physicians recommend lip cosmetics with sunscreening agents to prevent recurrent herpes labialis, photoaging, and lip cancer. Early studies have shown that lip balms cannot be assumed to provide effective protection in rigorous conditions. In 1981, standard army issue sunscreening lipsticks for hot and cold weather were tested for protection from four minimal erythema doses (MEDs) with a xenon solar simulator in rabbits.23 These products afforded no significant protection. The authors had used off-the-shelf products and were concerned that these sticks may have deteriorated from age or improper storage. In 1983, Shulman and studied soldiers on desert maneuvers where the average temperature was 37°C centigrade and the relative humidity was 29.5%. These oral pathologists examined 1053 of the 2500 participating soldiers for signs of chapped lips during the third week of this desert training program. Lip chapping was classified as severe if there was cracking, crusting, or bleeding of the vermilion border and classified as moderate if scaling, desquamation, and dryness were noted. One third of the soldiers
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were noted to have chapped lips-in 10% ( n = 150), chapping was severe, and in 23.5% ( n = 247), it was moderate. The soldiers had been issued a lip protectant stick with p-aminobenzoic acid (otherwise not characterized) and were interviewed regarding its use at the time of examination. The data showed no correlation between the use of the lip protectant and avoidance of chapping. The study is flawed because the soldiers may have answered in the affirmative believing compliance would put them in a favorable light with their superior officers, frequency and method of use were not evaluated, and the composition of the stick was not revealed. In both these studies, the army issue products did not bear a SPF number, which is an important guide for the consumer buying commercial products. the In the study by Shulman and soldiers that used the lip protectant with sunscreen had a reduction in the incidence of recurrent herpes labialis. Laboratory studies can provide stronger evidence that application of sunscreening agents to the lips can prevent UV light-induced recurrent herpes labialis. Rooney et a133 studied 38 patients with a history of recurrent herpes labialis. These subjects were given four MEDs of UV light to a site on their lips where they had experienced herpes labialis on two occasions. A commercially available SPF 15 sunscreening lotion was applied before the radiation on one of the occasions and a placebo lotion on the other. Twenty seven of the 38 (71%) experienced a recurrence of herpes labialis when the placebo was used, and none of the subjects experienced a clinical recurrence when the sunscreen was applied. One subject using the sunscreen showed viral shedding of herpes simplex type 1. This protective effect is more difficult to show outside the laboratory when the radiation is less intense. In a study of 51 skiers with histories of skiing triggering herpes labialis, there was only a 12% recurrence rate during 1 week of skiing, and no protective effect of frequent sunscreen use could be shown.26It is estimated that 150 million Americans have latent herpes simplex virus type 1 infection and that there are 100 million episodes of recurrence each year.33 In light of the experimental evidence, coupled with
patients' anecdotal experience, most dermatologists recommend conscientious use of lip sunscreens for patients with a history of recurrent herpes labialis. An epidemiologic study explored whether the recognized dramatically lower incidence of lip cancer in women compared with men even after tobacco use is accounted for may be partially attributed to the UV light protective effect of lip cosmetics.30Comparing the female subjects with lip cancer with a control group of women, those with high lifetime solar radiation exposure who used lip protection only once daily or less often had twice the risk of lip cancer. Colored lipstick without added sunscreening chemicals was counted among the lip-covering protectants. This study suggests that sun exposure plays a causative role for lip cancer and that use of lip cosmetics can reduce that risk. The use of lip sunscreens for men and women appears to prevent actinic damage of the vermilion border, and for women, colored lipsticks seem to offer some benefits, although this undoubtedly varies with the pigment content and frequency of application.
BEAUTlFlCATlON Physicians should not underestimate the importance of cosmetics for decoration and correction. In one study, two women who suffered postoperative facial nerve palsy were taught corrective makeup techniques, including using lipstick to correct asymmetry of their mouths.22The results of personality assessment testing administered before and after instructions showed positive findings, including reduction in depression and feelings of inferiority. Draelos'O has discussed the use of lip cosmetics to improve the appearance of elderly women by camouflaging lentigines, venous lakes, and actinic cheilitis with densely pigmented lipsticks. She has illustrated artfully how to correct asymmetry or change the appearance of the size of the lips with lip liner and a matte finish lipstick. Many patients would benefit from a discussion of the use of lip and other cosmetics to improve their appearance and their spirits.
LIP COSMETICS
References 1. Andersen KE, Nelsen R: Lipstick dermatitis related to castor oil. Contact Dermat 11:253, 1984 2. Arquette J, Cummings M, Reinhart J: Jojoba esters in lipsticks. Cosmetics Toiletries 113:63, 1998 3. Baran R, Chivot M, Shalita A R Acne. In Baran R, Maibach HI (eds): Textbook of Cosmetic Dermatology, ed 2. London, Martin Dunitz, 1998, p 431 4. Calnan CD: Allergic sensitivity to eosin. Acta Allerg 13:493, 1959 5. Calnan CD: Quinazoline Yellow SS in cosmetics. Contact Dermat 2:160, 1976 6. Cronin E (ed): Cosmetics. In Contact Dermatitis. London, Churchill Livingstone, 1980 7. de Groot AC, Weyland JW, Nater JP (eds): Face cosmetics. In Unwanted Effects of Cosmetics and Drugs Used in Dermatology, ed 3. New York, Elsevier, 1994, p 498 8. de Darko E, Osmundsen PE: Allergic contact dermatitis to Lipcare lipstick. Contact Dermat 11:46, 1984 9. Downs AMR, Lear JT, Sansom JE: Contact sensitivity in patients with oral symptoms. Contact Dermat 39258, 1998 10. Draelos ZD (ed): Lip cosmetics. In Cosmetics in Dermatology, ed 2. New York, Churchill Livingstone, 1995 11. Duke D, Urioste SS, Dover JS, et al: A reaction to a red lip cosmetic tattoo. J Am Acad Dermatol 39:488, 1998 12. Faulkner EB: Formulating decorative cosmetics with certifiable colors: Past, present and future. Cosmetics Toiletries 10429, 1989 13. Fed Reg 48(32) Feb. 15, 1983, p 5 14. Ferguson JE, Beck MH: Contact sensitivity to vanilla in a lip salve. Contact Dermat 33:352, 1995 15. Freeman S, Stephens R: Cheilitis: Analysis of 75 cases referred to a contact dermatitis clinic. Am J Contact Dermat 10:198, 1999 16. Fox C: Color in cosmetics. Cosmetics Toiletries 111:35, 1996 17. Gray H: Anatomy, Descriptive and Surgical: A Revised American, from the Fifteenth English, Edition. New York, Bounty Books, 1977, pp 869-870 18. Green MR, Pastewka JV:Mutagenicity of some lipsticks and their dves. T Natl Cancer Inst 64:665, 1980 19. Hemmer W, Fock;! M,-Gotz M, et al: Pigmented contact dermatitis of the lips from a lipstick. Contact Dermat 37244, 1999 20. Hoffmann C, Schuller-Petrovic S, Soyer P, et al: Adverse reactions after cosmetic lip augmentation with permanent biologically inert implant materials. J Am Acad Dermatol40:100, 1999 21. IARC Monogr Eva1 Carcinog Risks Hum 57203,1993 22. Kanzaki J, Ohshiro K, Abe T: Effect of corrective make-up training on patients with facial nerve paralysis. Ear Nose Throat J 77270, 1998 23. Kessler HP, Webb JG: An evaluation of actinic blocking agents. Milit Med 146339, 1981 24. Lim JTE, Ng SK, Goh C L Contact cheilitis in Singapore. Contact Dermat 27263, 1992
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