Systemic contact dermatitis of the eyelids caused by formaldehyde derived from aspartame?

A 60-year-old Caucasian woman presented with a 6-month history of eyelid dermatitis. A corticosteroid-containing ophthalmologic ointment improved but did not clear the rash. She failed to improve when she discontinued the use of all eyelid cosmetics and nail polishes for 2 months. She had had a facial dermatitis in 1995, for which she had been patch tested and found to be allergic to formaldehyde, quaternium15 and fragrances. She had also had incidental, non-relevant reactions to neomycin and ethylenediamine. Her dermatitis had resolved with a change to formaldehyde-, quaternium-15and fragrance-free facial and nail cosmetics. There was no personal or family history of atopy or psoriasis. Her only oral medication was celecoxib that she had taken for years prior to the onset of her blepharitis. She had also taken multivitamins, calcium and flaxseed oil for many years. She worked as a homemaker and library volunteer. Her eyelid dermatitis was kept clear with tacrolimus 0.03% ointment 2 daily. She underwent patch testing to the North American Contact Dermatitis Group standard tray, the University of Kansas’ supplemental standard tray, and to her cosmetics, cleansers, skin and hair care products and topical medications. She had relevant positive reactions at days 2 and 4 to formaldehyde (þþ), quaternium-15 (þþ), diazolidinyl urea (þ), DMDM hydantoin (þ) and imidazolidinyl urea (þþ), her hair care products and cleansers containing multiple sources of these allergens. She was extensively instructed in avoidance of formaldehyde and formaldehyde releasers, as well as that of her multiple, currently non-relevant allergens, including fragrance, benzalkonium chloride, neomycin, bacitracin, p-phenylenediamine and black rubber mix. By strictly avoiding formaldehyde and all formaldehyde releasers for the next 3 weeks, she improved only slightly. Her problem, however, was subsequently solved when a local pharmacist advised her to avoid aspartame. She had begun using an aspartame-based artificial sweetener 5 months prior to the onset of her dermatitis. Within 1 week of discontinuing theaspartame, her eyeliddermatitis resolved completely and has not recurred over 18 months without specific treatment. Unfortunately, she refused to undergo rechallenge with the sweetener.