Acute Rash Station

Presenting Complaint:

Swollen, itchy and painful rash around the mouth for the past few days.

Quote:
"My lips and the skin around my mouth are red, itchy, and swollen. It started a few days ago and seems to be getting worse."

Symptoms (SOCRATES):

• Site: Around the mouth and lips
• Onset: 2 days after using new brand of lipstick 
• Duration : 3 days
• Character: Very dry, itchy and, painful rash
• Radiation: None
• Associated symptoms: Difficulty eating as cannot open the mouth fully because of dryness and pain
• Time: Constant discomfort since onset
• Exacerbating/Alleviating factors: Worse after using a new brand of lipstick, slightly relieved with cold compresses, ongoing use of lipstick has worsened the rash
• Severity: Moderate to severe – affecting sleep and daily activities because of itchiness and pain

Other Negative Findings:

• No rash in other part of the body including scalp, nails and oral mucosa
• No lip-licking described or observed
• No other new cosmetic appliances used

Systemic Review:

• Weight loss, loss of appetite, night sweats – No
• Fever – No
• Fatigue – Yes due to poor sleep from discomfort
• Headache or dizziness – No
• Eye ulcers – No
• Bone pain – No
• Lymphadenopathy or masses – No
• Cough, dyspnoea, haemoptysis – No
• Chest pain, palpitations – No
• Change in bowel habit – No
• Urinary symptoms – No

Past Medical History:

• Asthma
• No previous skin disease
• No history of malignancy, surgery, or hospitalisation
• Fully vaccinated
• Had similar rash with lipstick when she was young, however, it disappeared after few days without worsening

Drug History:

• Salbutamol inhaler as required. Has been required every morning over the last few days since the rash started.

Allergies:

• No known drug allergies

Social History:

• Occupation: Customer Service Representative in a Marketing Team which needs regular use of makeup, especially lipstick, as part of professional appearance

• Smoking: Non-smoker
• Alcohol: Occasional
• Functional status: Independent, full-time work
• No recent travel

Family History:

• No family history of skin conditions or cancer

Ideas, Concerns, and Expectations (ICE):

• Ideas: Thinks the rash could be a reaction to a new lipstick
• Concerns: Worried about the appearance and the pain worsening which is different from her childhood experience
• Expectations: Wants relief from the rash and the symptoms, and guidance on avoiding recurrence

Observations:

• Respiratory rate: 18/min
• SpO₂: 96% on air
• BP: 132/78 mmHg
• Pulse: 82 bpm
• Temperature: 36.8°C
• Consciousness: Alert and oriented

NEWS Score: 0

General Inspection:

• Appears mildly anxious

Images sourced from DermNet in accordance with image licensing policy. 

Available here : https://dermnetnz.org/topics/eczematous-cheilitis, Image licence and Deed - Attribution-NonCommercial-NoDerivatives 4.0 International - Creative Commons

• Distribution: Localised dry erythematous rash around the perioral area
• Size: Diffuse area covering upper and lower lips
• Shape: Irregular but sharply demarcated
• Colour: Bright red with slight oedema
• Margins: Well defined
• Bleeding: None
• Surrounding skin: Inflamed, no signs of secondary infection
• Mucosa: Intact
• Nails and hair: Normal
• Lymph nodes: No cervical or submandibular lymphadenopathy

Patient questions

1. I’m worried this rash around my mouth is getting worse. Is it something serious? What’s causing it?

Example answer: "From what you’ve told me and what I can see, this rash is most likely due to an allergic reaction, something called allergic contact dermatitis. That means your immune system is reacting to something your skin has recently come into contact with. You mentioned using a new lipstick, and this fits well with the timing and the area affected. It’s very likely your skin is reacting to one of the ingredients in that product.

The good news is that this isn’t something dangerous or contagious, and it’s usually very manageable once we identify and avoid the cause."

2. How can I get rid of it?

Example answer: "The first and most important step is to stop using the new lipstick straight away. I’ll prescribe a mild steroid cream, such as 1% hydrocortisone, to reduce the inflammation and itching around your mouth.

We’ll also use a moisturiser or emollient to protect your skin while it heals. If the itching is bothering you, an antihistamine tablet can help relieve that. 

Please avoid spicy or acidic foods that may worsen discomfort, and also to apply the emollients at all times to avoid crusting or delay wound healing from the dryness."

3. What if it doesn’t get better or happens again? How can I prevent it from happening again?

Example answer: "This is usually a short-term problem and should start improving within a few days. If it doesn’t get better in a week, or if it gets worse, please come back and we’ll reassess.

If it happens again in the future, we might need to refer you to a dermatologist for a patch test. That’s a specialised test that can help us identify the exact substance your skin is reacting to, so you can avoid it in the future."

4. Why has this gotten worse now? I had the same kind of rash when I was younger, but it went away on its own.

Example answer: That’s a really good question. Allergic reactions can change over time. Your body might have had a mild sensitivity when you were younger, which didn’t cause much of a problem. But now, with repeated exposure to certain ingredients or even changes in the formulation of the product, your immune system may be reacting to a stronger response.  This process is called sensitisation, and it can make reactions more severe even to things you’ve used before. Other factors, like stress, cold weather, or even having dry or damaged skin, can also make your skin more reactive now than it was in the past.

Examiner Questions

1. What is your differential diagnosis?

• Allergic contact dermatitis/ Cheilitis most likely due to new lipstick. Given the patient's atopic background and recent asthma flare requiring daily salbutamol use, the development of a rash and cheilitis is most likely due to allergic contact dermatitis secondary to a new lipstick. The reaction appears consistent with a delayed Type IV hypersensitivity response, occurring a few days after starting the new product.
• Oral allergy syndrome, however the onset and recovery are more rapid in OAS.
• Herpes simplex virus, however there were no vesicles.
• Perioral dermatitis.
• Angular cheilitis.

2. Which investigations would you request?

• Clinical diagnosis is often sufficient
• Patch testing can be performed if recurrence or allergen needs to be identified
• Viral/bacterial swab (if superimposed infection or HSV is suspected)

3. What is your treatment plan?

• Avoid allergen: stop using the suspected new lipstick
• Topical corticosteroids: low potency topical steroid, e.g., hydrocortisone 1% cream for perioral area
• Oral antihistamines: for itching and comfort
• Emollients: to protect and restore the skin barrier, moisture also enhance the wound healing compared to the dry state
• Oral care:  avoid spicy or acidic foods that may worsen discomfort, to apply the emollients at all time to avoid crusting or delay wound healing from the dryness
• Advice: educate on allergen avoidance, discuss patch testing if recurrence
• Follow-up: review in 5 - 7 days or sooner if symptoms worsen