Allergic contact dermatitis caused by glycyrrhetinic acid and castor oil

A 19-year-old woman with a past history of eczematous lesions at sites of contact with costume jewellery and adhesive dressings was referred for investigation of repeated episodes of contact dermatitis that occurred over a period of 3 years. The lesions involved the lips, the axillae, and the face. The patient implicated two lip balms, a deodorant, and a post-sun moisturizing cream. Patch testing was performed in two separate sessions. In August 2008, the patient was first tested with the North American Contact Dermatitis Group baseline series (AllergEAZE™; SmartPractice® , Calgary, Canada) applied on Finn Chambers® (SmartPractice® , Phoenix, AZ, USA), the antimicrobials/vehicles/cosmetics series, and the four suspected cosmetics, applied on IQ Ultra® chambers (Chemotechnique Diagnostics AB, Vellinge, Sweden) (Table 1). The patches were removed at D2, and the reactions were scored according to the criteria of the International Contact Dermatitis Research Group at D2 and D4. The patient's positive reactions to colophonium and nickel sulfate were deemed to be of past relevance. She had strong reactions to each of her four cosmetics, none of which contained benzalkonium chloride. The relevance of this last reaction remained undetermined (Table 1). The manufacturers of the cosmetics provided their separate ingredients, and a second session of patch testing took place in June 2010 (Table 2). Positive reactions were seen to Ricinus communis seed oil, present in Labello® NIVEA Med Protection Lip Balm (Beiersdorf AG, Hamburg, Germany) and Lipolèvres lip protector (La Roche-Posay Laboratoire Dermatologique, La Roche-Posay, France), and to glycyrrhetinic acid, an ingredient common to Lait Après Soleil (Lancôme, Paris, France) and to Déodorant Peau Très Sensible (Laboratoires Vichy, Vichy, France). The oil extracted from the seeds of R. communis, or the castor oil plant, is used in most lipsticks as a humectant and pigment stabilizer. Its main fatty acid is ricinoleic acid, and allergic contact dermatitis caused by it and its derivatives, although rare, has been repeatedly reported (1–4). Glycyrrhetinic acid, or enoxolone, is a pentacyclic triterpene derived from the hydrolysis of glycyrrhizic acid (glycyrrhizin), one of the main components of licorice root, or Glycyrrhiza glabra. Because of its steroid-like chemical structure, it possesses anti-inflammatory activity, as well as antibacterial, antiviral and antifungal activities. In a mouse model of allergic contact dermatitis, glycyrrhetinic acid showed weak inhibitory activity (5). As an ingredient in Atopiclair® (Graceway Pharmaceuticals, Bristol, TN, USA) it is used for its anti-inflammatory and antipruritic effects in the treatment of atopic dermatitis (6). Allergic contact dermatitis caused by glycyrrhetinic acid appears to be extremely rare, as we could find only three previous reports (7–9). One publication describes delayed facial angioedema following oral ingestion (10), and another mentions allergic contact dermatitis caused by glycyrrhizin in a topical hair-restoring preparation (11). Our patient's reactions to R. communis and to glycyrrhetinic acid represent concomitant reactions, as the two molecules have completely different chemical structures (Fig. 1). Her weaker reaction to the higher concentration of glycyrrhetinic acid may be explained on the basis of its anti-inflammatory effect, as seen when testing with topical glucocorticosteroids (12). Given the recent increase in the use of glycyrrhetinic acid in cosmetics and therapeutic adjuncts, we expect to see more cases of allergic contact dermatitis in the future. Chemical structures of glycyrrhiretinic acid and ricinoleic acid.

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