A Case of Severe Contact Dermatitis to Topical Steroids Affecting the Lower Lip: Why Less is Sometimes More.

A 75 year old patient was referred to the Oral Medicine unit at the Dublin Dental University Hospital in relation to extensive painful ulceration of the lower vermilion border. She had no rash or nail or genital symptoms. She had a history of basal cell carcinomas and was under the care of a dermatologist. Her medical history was otherwise non-contributory.

She had been referred by her dentist 2 years previously to an oral surgeon in relation to a sore red area on the right lower lip of four weeks duration. Biopsy showed non-specific findings, but a working diagnosis of lichen planus was made. The patient was trialled on betamethasone ointment. However, the lip deteriorated dramatically with the development of extensive ulcerative cheilitis of the entire lower vermilion border. This had a significant impact on the patient’s quality of life and she required oxycodone for pain management. A prolonged course of clobetasol propionate 0.05% ointment had been prescribed and there had also been a short-trial of tacrolimus ointment with no effect.

Examination in our unit revealed perioral dermatitis, extensive lip ulceration and angular cheilitis. Intra-oral examination was normal. The patient was advised to discontinue topical steroids and to apply only lanolin to the lip. Microbiological swabs were taken which confirmed the clinical suspicion of superinfection with Staphylococcus aureus which was treated with fusidic acid. Biopsies for histopathology and direct immunofluorescence were carried out. Histopathology showed ulcer slough, solar elastosis and epithelium showing carcinoma in situ. Direct immunofluorescence was negative. Following discussion at a clinico-pathological conference it was agreed that the atypia seen could be explained by the degree of inflammation. The lip rapidly improved following withdrawal of topical steroids and complete resolution occurred. This case highlights the importance of appropriate investigation and management of unusual cases, and the value of clinico-pathological conferences.