DERMATOLOGIC ASPECTS OF COSMETICS 0733-8635100 $15.00 + .

OO

LIP COSMETICS
Patricia G. Engasser, MD

”The lips are two fleshy folds which sur- scorned by societies. Following the Victorian
round the orifice of the mouth, formed exter- era in 1915, its popularity grew again, and
nally by integument and internally by mu- Levy persuaded the Scovill Manufacturing
cous membrane, between which are found Company to produce lip rouge in a handy
the Orbicularis oris muscle, coronary vessels, stick that was sold in a push-up case.41Lipstick
nerves, areolar tissue, and fat and numerous was created, and the swivel case soon fol-
small labial glands.”17This anatomic descrip- lowed. In 1919, the Morton Manufacturing
tion of human lips appeared at the beginning Company, in Lynchburg, VA, began the man-
of the twentieth century. In the new millen- ufacture of Chap Stick, a lip balm to treat
nium, it is understood that lips are much dryness and peeling.
more than the sum of their parts. 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
HISTORY
shades with romantic titles such as Fire and
Ice and Cherries in the Snow, dramatizing this
Through the centuries, the beauty of the in elaborate, color, pictorial advertisements in
lips has been extolled by poets and painters. women’s magazines. Fashion is fickle, and
Red, full, moist, relaxed, slightly parted lips pale lip colors prevailed in the early 1970s,
are considered sensuous. People in primitive but women continued to apply lipstick.
cultures have stretched lips to gigantic pro- In the 1990s, dazzling colors created with
portions by inserting wooden disks; in more newer pigment technology boost the sales of
advanced developed countries, people plump these ever-popular cosmetics. Lipstick‘s ap-
the lips up by implanting bovine collagen peal extends to women of all ages; it fre-
and Gore-Tex threads.20Egyptian and Assyr- quently is the first cosmetic used by adoles-
ian women painted their lips with plant mate- cents, and elderly women apply it daily.
rial thousands of years ago. In the eighteenth Many women do not feel dressed without it.
century, Japanese women painted rouge on Recovering patients apply lipstick because
their mouth in a classic ochoboguchi style to they feel better, and their appearance with the
express innocence, and contemporary Japa- lipstick gives them a psychologic boost. Most
nese brides continue this custom.32Rouging women in the United States present a face to
lips alternatively has been indulged or 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

-
VOLUME 18 NUMBER 4 OCTOBER 2000 641
642 ENGASSER

CATEGORIES lar to the action of surfactants for an oil and

water solution, but oleyl alcohol has a double
Lipsticks bond, making it more susceptible to oxidation
and rancidity. Fatty esters, such as octyl pal-
Lipsticks are cosmetics applied to the ver- mitate, increase slip and impart a lighter feel.
milion border to impart color and to define By balancing the amounts of wax and emol-
shape as well as provide protection from en- lients, the creator of a lipstick can determine
vironmental conditions. They commonly are if the cosmetic is one that is firm and resists
solid mixtures of lipids that soften at body feathering-a term used to describe the creep-
temperature for smooth application-they are ing of color up the fine lines around the
designated as thermoplastic for this reason. In mouth. Lipsticks with a high emollient con-
addition to the visual characteristics they im- tent impart a lubricious feel and give a moist
part, consumers expect these cosmetics to appearance that is considered alluring, but
give a pleasant, smooth feeling to this area of they do not stay on the lips as well. Long-
mucous membrane, which becomes dry and wearing lipsticks have higher wax content in
peels easily. Lipsticks are left on the lips (75 relation to emollients to allow longer pigment
to 300 mg per application) and must be safe deposition, but they feel drier to the con-
to ingest. They should not have an unpleasant sumer and are less glossy.* Silicones are a
taste or odor. Lipsticks are composed of five special class of polymers that have become
categories of ingredients-waxes, emollients, popular additions to lipsticks in the 1990s.
marketing and functional ingredients, stabi- They are inert, inexpensive, and colorless,
lizers, and colorants. and some are volatile. Dimethicone imparts
barrier properties and, when present at 1%
concentration, can allow an antichapping
Waxes
claim to be made. Volatile silicones (e.g.,
Waxes give structure to lipsticks, and be- cyclomethicone and low-molecular-weight di-
cause no single wax provides ideal texture, methicones) act as oils on application. As the
heat stability, and application and wear char- lipstick sets, these silicones evaporate, and
acteristics, mixtures are used. The blends of the remaining pigments resist transfer to
waxes can be plant derived, such as carnauba, cups, glasses, and kissed cheeks. Transfer-
candelilla, and rice bran, or petroleum de- resistant lipsticks have a matte or dry finish
rived, such as paraffin, ceresin, microcrystal- and do not have a lubricious gloss. They are
line wax, and polyethylene. generally sold in slender cases that snap shut
to prevent evaporation.
Emollients
Miscellaneous Enhancing Ingredients
Emollients plasticize the waxes. In addition
to providing moisturization and emolliency Miscellaneous enhancing ingredients in-
for the lips, they modify the application char- clude materials that add function or market-
acteristics of slip, tack, and drag. A critical ing appeal. For example, menthol or camphor
balance of these characteristics in the product is added to impart a cool sensation on appli-
must be achieved for a desired esthetic result cation and to give the impression of active
on the lips. Emollients impart gloss and allow ingredients. Lipsticks are regulated as over-
pigment wetting and dispersion. Popular nat- the-counter drugs when chemical or physical
ural emollients include castor oil, jojoba oil, sunscreens are added, and they are labeled
and lanolin derivatives. Synthetic esters, with a sun protection factor (SPF). Ordinary
polymers for film forming, and hydrocarbons lipstick pigments generally do not provide
are other important components. Isostearyl more than a SPF 4 protection (R. Sandewicz,
alcohol is a liquid with a low melting point personal communication). The popularity of
that wets pigments, allowing their disper- vitamins, antioxidants, and botanicals has led
sions in this lipid mixture. Oleyl alcohol wets to their appearance in lipsticks.
pigments and acts as a coupling agent, which Flavoring agents are added, especially to
allows the combination of different oils simi- lip salves, that appeal to younger consumers
 LIP COSMETICS 643

as a selling point. Fragrance mixtures are (Ext. D&C) group cannot be allowed on mu-
common ingredients. In lipid preparations, cous membranes or ingested and is unsuit-
masking agents are used to cover unpleasant able for lip cosmetics (Table 1). The European
odors (e.g., ethylene brassilate, mint, or men- Community and the Japanese lists of ap-
thol). proved colors differ in many respects from
those of the United States. The Europeans
have a larger number of approved colors and
Stabilizers
employ the Color Index number for identifi-
The shelf life of a lipstick is generally 2 to cation.28
5 years. Lipsticks usually are anhydrous and For lipsticks, insoluble pigments or lakes
easier to preserve from bacterial contamina- are used for coloring. Lakes are pseudopig-
tion than formulations made with water. ments produced by precipitating water-solu-
Emulsion lipsticks can be formulated to create ble colorants with water-insoluble salts, such
a more emollient product, but they are un- as aluminum hydroxide. Lakes are virtually
common.42Antimicrobials commonly used in insoluble, and they can be handled as pig-
lipsticks are the parabens and phenoxyetha- ments. Formerly the indelible lipsticks used
nol. These products often are preserved with bromo colors, such as eosin (D&C Red No.
antioxidants, such as butylhydroxyanisole 21), but they left a cherry red color on the lips
(BHA) or one of the gallates, particularly and are unpopular at present. Sophisticated
when unsaturated lipids are present. complex colors are used in many modern lip-
sticks. The use of pearlized colors has brought
dramatic changes. They produce reflectance
Colorants
similar to tiny mirrors or interference de-
Market research has established that the pending on the coating thickness for Ti02/
most important reason for a consumer to pur- mica. Powders, such as organically modified
chase a lipstick is its color appeal. The range clays, silica, mica, or polymethyl methacry-
of colors is astonishing considering the pallet late, also absorb oils, reduce bleeding of col-
of the cosmetic chemist has been significantly ors, and can enhance the tactile sensation.
diminished in the last 4 decades. In 1959, Producing uniformly colored, esthetic lip-
there were 116 certifiable colors approved for sticks, which are stable under extreme envi-
use in cosmetics in the United States, and that ronmental conditions, requires the talents and
number has been reduced to 34 at present.31 knowledge of an experienced cosmetic chem-
Until the twentieth century, there was little ist. Lipsticks are heated during manufacture
regulation of the safety of colors added to to 5" above the highest melting point of the
foods, drugs, and cosmetics, with some waxes, the milled pigments are mixed in, and
deaths resulting. The 1938 Food, Drug, and the batch is poured into molds. The molded
Cosmetic Act required that each batch of or-
ganic colorants must be confirmed as con-
forming to established standards to be certi- Table 1. COLORING AGENTS FOR LIP COSMETICS
fied. The 1960 Color Additive Amendments
Certified Certification Not Required
allowed the Food and Drug Administration
(FDA) to set limitations on the amounts of D&C Orange No. 5 Titanium dioxide
D&C Red No. 6 Mica
color used. The manufacturers were required D&C Red No. 7 Zinc oxide
to submit data on the safety of the colorants. D&C Red No. 21 Iron oxides
Colorants are either organic or inorganic; D&C Red No. 22 Carmine
D&C Red No. 27 Bismuth oxychloride
approved inorganic colorants, such as tita- D&C Red No. 28 Bronze powder
nium dioxide (Ti02) or iron oxides, do not D&C Red No. 30 Ultramarines
require batch certification. In the United D&C Red No. 33
D&C Red No. 36
States, approved organic colors are desig- D&C Yellow No. 10
nated for Food, Drug and Cosmetic (FD&C) FD&C Blue No. 1
or Drug and Cosmetic (D&C)groups, both of FD&C Yellow No. 5
FD&C Yellow No. 6
which may be used on mucous membranes or
ingested, but the External Drug and Cosmetic Dntafrom references 28 and 43.
644 ENGASSER

lipsticks are passed through a gas flame to prevents dryness or chapping of the exposed
create a smooth, shining surface for eye ap- surface of the lip.”I3 The vermilion border is
peal. devoid of sebaceous or salivary gland and
Lipsticks vary in functional characteristics dries easily. Chapping is a reaction to envi-
depending on their composition (Table 2). ronmental conditions, especially to cold or
Oils give slip, a lighter feel, more gloss, and hot dry winds. The keratin of the vermilion
a tendency for colors to bleed. Waxes add to border becomes inflexible or brittle, then
the tack and drag, resulting in longer wear, cracks and peels. Subjects may lick their lips
less bleeding, and diminished gloss. or pick at the flakes, aggravating the condi-
Lip Liners. Lip liners are modified lipsticks tion. Lip balms provide a barrier of protec-
used to define the outline of the lips and to tion. To qualify as a lip balm, a product must
deposit a high pigment content that is not contain one of the following:
mobile. These commonly are sold as pencils Allantoin, 0.5% to 2%
that can be sharpened, but they can be made Aluminum hydroxide gel, 0.15% to 5%
in thin swivel containers. Lip liners are effec- Calamine, 1%to 25%
tive when the natural lip contour is being Cocoa butter, 50%
modified or corrective makeup is being ap- Dimethicone, 1%to 30%
plied. Using lip liners decreases the feath- Glycerin, 20% to 45%
ering of lipstick into the lines around aging Kaolin, 4% to 20%
lips. Petrolatum, 30% to 100%
Lip Glosses. Lip glosses have little wax Shark liver oil, 3%
and high oil content and are not in molded White petrolatum, 30% to 100%
sticks. These are sold in pots or containers Zinc acetate, 0.1% to 2%
with a wand for application. They have low Zinc carbonate, 0.2% to 2%
color content and make the lips shine. Some Zinc oxide, 1%to 25%
of these are marketed to young consumers
and are heavily fragranced and flavored with Some of these ingredients could raise con-
fruit flavoring. Glosses do not stay on the cerns about comedogenicity and exacerbating
lips well and migrate into the lip lines in perioral comedones in patients with acne.36
mature women. Dermatologists find these products useful for
Liquid Lipsticks. Liquid lipsticks usually treating the lip chapping that often accompa-
are anhydrous with less wax than conven- nies oral retinoid the rap^.^
tional lipsticks. Similar to lip glosses, they are
not molded into sticks, but liquid lipsticks Lip Sunscreens
contain a high pigment content that appears
more transparent. They can be transfer resis- Chemical sunscreening ingredients are
tant. added to a colorless lipstick or lip balm to
attain usually an SPF of 8 or greater. Colored
lipsticks also are incorporating sunscreening
Lip Balms agents. Once the SPF claim is made, these
lipsticks are regulated as over-the-counter
A lip balm is an over-the-counter drug de- drugs as well as cosmetics. Ordinary effective
fined as ”a drug product that relieves and sunscreens for glabrous skin are less effective

Table 2. LIPSTICK FORMULATIONS

Ingredients Lip Gloss Creamy Lipstick Long-Wearing Lipstick Transfer-Proof Lipstick Lip Liner
Waxes 3-8% 10-15% 15-20% 10-15’Xo 1525%
Volatiles None None None 35-40% Varies
Oils/ semisolids 70-8OYo 60-70% 50-6OYo lo-20% 40-50%
Colors and uowders 0-5% 10-15% 10-15% 10-20% 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 645

for the lips because lip sunscreens must have whose vision or motor skills are impaired so
unique properties of adherence that resist fric- that they are unable to apply lipstick cor-
tion and licking rectly. Some consumers choose lip tattooing
because they want color that will not migrate
into wrinkles, or they wish to avoid the
Lipstick Primers bother of applying lipstick frequently. Be-
cause fashion changes constantly, the perma-
Lipstick primers, which come in stick or nency of this decorative procedure makes it
cream form, act as a foundation for lipstick undesirable for most women.
to help it adhere and to fill in the fine creases The pigment is applied using a motorized
around the mouth. They allow a smoother instrument with a single or multiple sterilized
application of lipstick. Some women apply needles often performed in repeated sessions.
liquid facial makeup as foundation to prepare Practitioners who apply these tattoos are phy-
the lips. sicians, other medical personnel, or lay tattoo
artists depending on state law or local ordi-
nances. There is no federal legislation that
Lipstick Overcoats regulates tattooing.39Practitioners, depending
on their qualifications and expertise, use ice
Lipstick overcoats are applied over lipstick packs, topical anesthetics such as a eutectic
to prevent it from coming off. They may con- mixture of lidocaine and prilocaine (EMLA
tain perfluoro compounds and powder of po- cream), injected local anesthetic, or a regional
lymethyl methacrylate.I6 block of the second and third branches of the
trigeminal nerve to mitigate any discomfort
or pain.45Anesthetic injected into the vermil-
Lip Treatment Products ion border has drawbacks because it causes
distortion and hematomas in some cases.
An array of specialty lip cosmetics are be- The manufacturers of pigments for tat-
ing introduced that are similar to products tooing consider their composition proprietary
used for facial skin care. Lip masks may in- information. The FDA does not inspect or
corporate exfoliating ingredients, and lip regulate tattoo pigment manufacturers and
makeup cleansers ease removal of lipstick to has not established comprehensive safety
avoid soiling bathroom linens. The real standards for intradermal use of pigments. In
expansion has been in products that incorpo- 1976, the FDA limited the concentration of
rate retinoids, alpha hydroxy acids, vitamins mercury to 3 parts per billion in these pig-
E and C, and other antioxidants, modeling ments, eliminating the use of cinnabar in the
themselves on the cosmeceuticals designed United States, but it still may be used in other
for other areas of the facial skin. There does nations, and lip micropigmentation is prac-
not appear to be published documentation of ticed around the world.
their efficacy for the lip area.

ADVERSE REACTIONS
Lip Tattooing (Micropigmentation)
Micropigmentation
In marked contrast to lipstick that colors
the lips for hours, micropigmentation colors Lip tattooing can trigger an episode of re-
the lips for years, although there is some fad- current herpes labialis, and medical prac-
ing with time. Lip tattooing is used to define titioners frequently administer oral antiviral
the lip margins with color similar to a lip drugs, such as acyclovir, prophylactically to
liner or, less frequently, to color the entire prevent this. Tattooing, unless performed un-
vermilion border. This procedure can help der universal precautions with scrupulous
correct the appearance of thin, asymmetric, sterile technique including sonic cleaning and
scarred, or dropping lips. It benefits patients autoclaving of the instruments, carries a risk
646 ENGASSER

of transmitting infectious diseases, including sorption. Ophaswongse and MaibachZ7have

viral hepatitis and human immunodeficiency hypothesized that absorption of materials ap-
virus (HIV) infection.39 plied directly to the vermilion border would
Granulomatous foreign body, allergic, and be high, but clinical data to establish that this
photoallergic reactions have been reported is the case have not been published.
from tattooing. Mercury accounted for most Contact dermatitis caused by lipstick may
of the allergic reactions to red tattoos, but in spread beyond the lips onto the face as it
the United States, its restriction has amelio- worsens. Some women use lipstick to rouge
rated this. Tattoo pigments may contain other their cheeks, and this habit can lead to the
metal pigments, including iron oxides, tita- appearance of lipstick contact dermatitis in
nium, silicon, cadmium, and aluminum. The unexpected areas on the A detailed his-
traditional red organic dyes are sandalwood, tory of each patient's makeup routine can be
brazilwood, and carmine from dried insect helpful in these cases. Lipstick seldom has
bodies. Lip micropigments are proprietary been reported to cause irritant contact derma-
mixtures that may contain organic FD&C titis or contact urticaria, but this may repre-
dyes. Allergic reactions to red skin tattoos sent a lack of recognition on the part of clini-
are infrequent but well recognized, so that cians. In one case, repeated episodes of
reactions to lip micropigmentation are to be burning and itching of the lips after applica-
expected and are quite troublesome. The few tion of a lipstick led to hyperpigmentation.
reported reactions are protracted and respond Patch testing was negative, and the authors
only partially to topical and intradermal corti- suggested a diagnosis of irritant contact der-
costeroids, and this therapy carries a risk of matitis.19
atrophy.40Laser destruction of tattoos on the The largest published review of cheilitis
lip presents a difficult problem because of the comes from Australia; 75 cases referred to a
risk of scarring in this cosmetically important tertiary contact dermatitis clinic were ana-
location." Q-switched lasers have darkened lyzed, and one quarter were due to allergic
the pigment of iron oxide by reducing it from contact dermatiti~.'~ Four cases were caused
ferric to ferrous oxide. Carbon dioxide laser by the ingredients in lipstick, and three cases
ablation has been proposed for removal of lip were caused by sunscreening lip balms; in
tattoos, but a series of cases has not been total, these products accounted for nearly
published to document its success." 10% of the cases of cheilitis. In a review of 27
In some cases of a delayed-type allergic consecutive patients with cheilitis from Singa-
reaction to tattoo pigment, patch testing can pore, one third of the patients had allergic
detect the allergen. If these results are nega- contact dermatitis; four cases were attributed
tive, intradermal testing with the individual to lipsticks, although in 2 patients, it was
pigments may be required to determine the believed that the nickel in the lipstick case
responsible agent.25 played a
In patients with puzzling cheilitis, patch
testing plays an important role in determin-
Cheilitis and Lip Cosmetics ing the diagnosis. Lipstick and most lip cos-
metics can be patch tested as is. In addition
Most reported adverse reactions caused by to a standard tray, personal care products, oral
lip cosmetics are of the delayed allergic con- hygiene products, UV filters, and a cosmetic
tact type. They appear on the external surface series should be included in the testingz7
of the lips, generally sparing the mucous
membrane inside the mouth. They are mani-
fest as erythema, scaling, and swelling and Allergens in Lip Cosmetics
may lead to blistering and occasionally hy-
perpigmentation. The cheilitis may not ex- Ophaswongse and Maibachz7reviewed re-
tend beyond the vermilion border and may ports of allergy to lipstick ingredients thor-
spare the angle of the mouth. The vermilion oughly to 1994, and de Groot et a17 provided
border does not produce a stratum corneum further information on concentrations of these
that is the major barrier to percutaneous ab- ingredients for patch testing.
 LIP COSMETICS 647

Colors Antioxidants
Before the 1960s, lipstick allergy was the Butylhydroxyanisole, tertiary butylhydro-
most common type of cosmetic allergy. Eosin quinone, and butylhydroxytoluene all have
was the bromofluorescein dye used in the been reported as allergens in lipsticks,& as
then popular indelible lipsticks that actually have octyl, dodecyl, and propyl gall ate^.^, 35
stained the lips. A chemical contaminant in
eosin caused most of the reactions? Now eo-
sin is purified better, and indelible ingredients Flavorings and Fragrances
are no longer popular so that these reactions Vanilla in a lip salve caused a recurrent
have all but vanished. Eosin was present at dermatitis in a 13-year-old girl, illustrating
the 1%to 2% level in indelible lipsticks, but that cheilitis in children may be related to lip
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
PROTECTI0 N
cochineal derived from the bodies of insects,
was reported as an allergen in lip salve.=
It is generally assumed that lip cosmetics,
D&C Yellow No. 11 was reported in three
cases of lipstick dermatitis in 1976, but that in addition to beautifying the lips, can protect
them from adverse environmental conditions.
dye is no longer permitted for use in lipstick
in the United state^.^ These environmental factors include irritation
from saliva, low humidity, wind, cold temper-
Many colorants, some of which were aller-
ature, and UV light exposure. The lips, ex-
gens, such as D&C Red No. 9,38are no longer
permitted in lipsticks in the United States for posed chronically to UV light, cannot respond
other reasons. In the 1970s and 1980s, color- as the skin does with the self-protective mech-
ants were screened extensively by the Ames anisms of tanning and hypertrophy of the
stratum corneum. It is important that physi-
test, and D&C Orange No. 17 was mutagenic
without microsomal activation.18 Animal cians recommend lip cosmetics with sun-
feeding and painting tests were carried out, screening agents to prevent recurrent herpes
and in one test of D&C Red No. 9, there were labialis, photoaging, and lip cancer.
Early studies have shown that lip balms
increased splenic sarcomas and liver neo-
plasms in rats.21The safety of D&C Red No. cannot be assumed to provide effective pro-
8, D&C Red No. 9, D&C Red No. 19, and D& tection in rigorous conditions. In 1981, stan-
dard army issue sunscreening lipsticks for hot
C Orange No. 17 was debated for years, but
the FDA permanently listed them for use in and cold weather were tested for protection
cosmetics. A consumer advocacy group suc- from four minimal erythema doses (MEDs)
cessfully challenged the action in the U.S. with a xenon solar simulator in rabbits.23
These products afforded no significant protec-
courts, and as of July 15, 1988, it became
tion. The authors had used off-the-shelf prod-
illegal to use these four colors in cosmetics
sold in the United States.12 ucts and were concerned that these sticks may
have deteriorated from age or improper stor-
age. In 1983, Shulman and studied
Waxes soldiers on desert maneuvers where the aver-
Microcrystalline wax in a lip salve caused age temperature was 37°C centigrade and the
allergic contact dermatitis in three consumers; relative humidity was 29.5%. These oral pa-
this may be patch tested as is or 10% in petro- thologists examined 1053 of the 2500 partici-
latum.8 pating soldiers for signs of chapped lips dur-
ing the third week of this desert training
program. Lip chapping was classified as se-
Emollients
vere if there was cracking, crusting, or bleed-
Castor oil, ricinoleic acid, and lanolins com- ing of the vermilion border and classified as
monly are present in lipsticks and have ac- moderate if scaling, desquamation, and dry-
counted for allergic cheilitis.', ness were noted. One third of the soldiers
648 ENGASSER

were noted to have chapped lips-in 10% ( n patients' anecdotal experience, most derma-
= 150), chapping was severe, and in 23.5% tologists recommend conscientious use of lip
( n = 247), it was moderate. The soldiers had sunscreens for patients with a history of re-
been issued a lip protectant stick with p-ami- current herpes labialis.
nobenzoic acid (otherwise not characterized) An epidemiologic study explored whether
and were interviewed regarding its use at the the recognized dramatically lower incidence
time of examination. The data showed no of lip cancer in women compared with men
correlation between the use of the lip pro- even after tobacco use is accounted for may
tectant and avoidance of chapping. The study be partially attributed to the UV light protec-
is flawed because the soldiers may have an- tive effect of lip cosmetics.30Comparing the
swered in the affirmative believing compli- female subjects with lip cancer with a control
ance would put them in a favorable light with group of women, those with high lifetime
their superior officers, frequency and method solar radiation exposure who used lip protec-
of use were not evaluated, and the composi- tion only once daily or less often had twice
tion of the stick was not revealed. In both the risk of lip cancer. Colored lipstick without
these studies, the army issue products did not added sunscreening chemicals was counted
bear a SPF number, which is an important among the lip-covering protectants. This
guide for the consumer buying commercial study suggests that sun exposure plays a
products. causative role for lip cancer and that use of
In the study by Shulman and the lip cosmetics can reduce that risk. The use of
soldiers that used the lip protectant with sun- lip sunscreens for men and women appears
screen had a reduction in the incidence of to prevent actinic damage of the vermilion
recurrent herpes labialis. Laboratory studies border, and for women, colored lipsticks seem
can provide stronger evidence that applica- to offer some benefits, although this undoubt-
tion of sunscreening agents to the lips can edly varies with the pigment content and fre-
prevent UV light-induced recurrent herpes quency of application.
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 BEAUTlFlCATlON
experienced herpes labialis on two occasions.
A commercially available SPF 15 sun- Physicians should not underestimate the
screening lotion was applied before the radia- importance of cosmetics for decoration and
tion on one of the occasions and a placebo correction. In one study, two women who
lotion on the other. Twenty seven of the 38 suffered postoperative facial nerve palsy were
(71%) experienced a recurrence of taught corrective makeup techniques, includ-
herpes labialis when the placebo was used, ing using lipstick to correct asymmetry of
and none of the subjects experienced a clinical their mouths.22The results of personality as-
recurrence when the sunscreen was applied. sessment testing administered before and
One subject using the sunscreen showed viral after instructions showed positive findings,
shedding of herpes simplex type 1. including reduction in depression and feel-
This protective effect is more difficult to ings of inferiority.
show outside the laboratory when the radia- Draelos'O has discussed the use of lip cos-
tion is less intense. In a study of 51 skiers metics to improve the appearance of elderly
with histories of skiing triggering herpes labi- women by camouflaging lentigines, venous
alis, there was only a 12% recurrence rate lakes, and actinic cheilitis with densely pig-
during 1 week of skiing, and no protective mented lipsticks. She has illustrated artfully
effect of frequent sunscreen use could be how to correct asymmetry or change the ap-
shown.26It is estimated that 150 million pearance of the size of the lips with lip liner
Americans have latent herpes simplex virus and a matte finish lipstick. Many patients
type 1 infection and that there are 100 million would benefit from a discussion of the use
episodes of recurrence each year.33 In light of lip and other cosmetics to improve their
of the experimental evidence, coupled with appearance and their spirits.
 LIP COSMETICS 649

References 25. McFadden N, Lyberg T, Hensten-Pettersen A: Alumi-

num-induced granulomas in a tattoo. J Am Acad
1. Andersen KE, Nelsen R: Lipstick dermatitis related Dermatol 20:903, 1989
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