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Contact cheilitis and other reactions involving the lips of musicians

Author: Dr Delwyn Dyall-Smith FACD, Dermatologist, 2010.

Cheilitis means inflammation of the lips. Inflammation and other reactions of the lips and adjacent skin can be due to contact with the mouthpieces of musical instruments, especially players of woodwind and brass instruments.

1. Red dry lips and calluses

The sound in brass instruments is created by the vibration of the lips inside a cup-shaped mouthpiece. Friction between the lips and mouthpiece can result in painful, red, dry lips and is unrelated to allergy. A callus on the upper lip may develop. Clarinetists and oboists may also develop a callus on the midline of the upper lip.

2. Lip trauma

Horn players may develop thinning (atrophy) of the central upper lip due to the pressure of the mouthpiece against the lip blocking the blood supply.

Woodwind and brass players may have soft tissue trauma to the lips due to pressure from their instrument pushing the lips against sharp edges of teeth and restorations. Such problem edges can be smoothed or rounded by the dentist, or lip shields can be worn.

3. Metal allergy

Allergic contact dermatitis to nickel and chromate have been reported in flautists, clarinetists, trumpeters, horn players and due to a nickel-plated harmonica. In most cases this presents as a cheilitis, except in flautists where an eczema-like reaction affects the chin just below the lower lip. Saliva and sweat between the skin/lip and mouthpiece contribute to the release of metal from the mouthpiece and the development of the allergy.

In one case report, examination of the trumpeter revealed scaling and crusting of the central one third of both lips. The trumpeter was able to substitute his nickel mouthpiece for one made from gold, resulting in improvement.

4. Cane reed allergy

Allergy to cane reed is reported in players of reed instruments, mainly saxophonists and clarinetists. Both immediate (Type I) and delayed (Type IV) reactions have been reported. The cheilitis affects the central lower lip presenting as redness and/or scaling. Swelling of the lip with associated itching of the tongue within minutes of exposure has been reported in immediate reactions.

Only the lower lip is involved in cane reed allergy due to a single reed woodwind instrument such as clarinet or saxophone as the reed is located on the undersurface of the mouthpiece.

The reed is made from Arundo donax, which belongs to the family Gramineae, subfamily Poaceae. Patch testing and scratch / prick testing can be performed using fine shavings from a cane reed. In some cases the patch test (for Type IV) or prick test (for Type I) reaction has only been positive with a new reed and in others only with a used one.

It has been suggested that the reaction is due to crossreactivity with allergens causing grass pollen allergies.

Substituting the cane reed with a plastic one has resulted in rapid improvement in some cases. However other musicians have not been satisfied with the resultant sound quality.

5. Exotic wood allergy

Allergic contact dermatitis to exotic woods used in the manufacture of wooden musical instruments has been reported. Allergic cheilitis has been noted in recorder players.

A recent case report described a recorder player who presented with an erosive cheilitis of the central one third of the lower lip. Patch testing to sawdust (10% in petrolatum) from his wooden recorders was performed with removal of the patches after one day to minimize the risk of an irritant reaction. He had positive reactions to African blackwood (Dalbergia melanoxylon) and rosewood, the latter being a cross reaction. Prick tests with the sawdusts (1% in water) were negative. The allergens in African blackwood and rosewood are quinones, (S)-49-methoxydalbergione and (S)- 49-hydroxy-4-methoxydalbergione.

6. Thiuram allergy

A case has been reported of a trumpet player who became sensitized to thiuram following a temporary black henna tattoo and then reacted to the mouthpieces of his brass instruments stored in foam rubber-lined cases. On patch testing he also reacted to the foam rubber of his instrument case, which contained thiuram (a rubber accelerant). The problem was solved by storing the mouthpieces separately.

7. Flautist’s chin

Flautist's chin is described as an acne-like rash with increased pigmentation on the chin where the flute rests. It is probably due to the combination of saliva, breath condensation and pressure from the flute against the skin.

8. Clarinetist's cheilitis

Clarinetist's cheilitis is usually a form of irritant contact dermatitis affecting the middle of the lower lip extending from the vermilion margin onto the chin. It is probably due to the combination of moisture (saliva, sweat), pressure and friction.

9. Black dermographism

Black discolouration of the lower lip/chin has been reported in a flautist due to an interaction between the silver of the flute and a sulphur/zinc containing lotion being used to treat perioral acne.



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