Edit concept Create issue ticket

Cheilitis

Cheilitides

Cheilitis is a condition of the lips characterized by the presence of inflammation and other manifestations that require medical intervention. Cheilitis comes in different forms, each of which will be discussed in greater detail in this review. In terms of the impact on the individual's health, cheilitis may precede or accompany certain underlying systemic disorders.


Presentation

  • Eczematous cheilitis: Reddish scaly eruptions are present in both lips and perioral skin with edema, fissures, vesicles and superficial ulceration [3]. The patient may complain of prurigo, burning sensation and tenderness of affected area and eczema in other parts of the body, depending on the source and manifestation of allergy aiding differential diagnosis.
  • Actinic cheilitis: This is characterized by a persistent area of dry and scaly lesions on the lower lip of older persons (40 and over), with a history of excessive solar exposure [22]. Single or multiple lesiions showing atrophy, erythema, edema, ulceration and flawed vermilion border in more advanced lesions are present.
  • Angular cheilitis: Painful lesions occur typically on both corners of the mouth, with fissures, reddening, maceration and scaling. The patient may complain of feeling the swelling and pain when touched and awareness of a dried sticky substance on the lips. In advanced suppurative cheilitis, mucopurulent exudate, superficial ulceration and crusting are likewise present.
  • Plasma cell cheilitis: Lesions in the form of discrete or flayed indurated erythematous plaques are mostly found on the lower lip indicating an inflammatory condition.
  • Cheilitis glandularis: Patients usually seek medical intervention within 3-12 months of onset of symptoms. The manifestations vary with regards to pain, degree of enlargement of the salivary glands, loss of elasticity of the lips and extent of superficial change.
  • Cheilitis granulomatosa: The onset of symptoms is an on-and-off upper lip swelling resembling angioedema. This worsens in time leading to persistent swelling possibly of both lips and resulting in disfigurement and functional disability. This type of cheilosis is rare and when found associated with facial palsy or plicated tongue, it is listed in medical literature under Melkersson-Rosenthal syndrome [23].
Cheilitis
  • A positive patch test is indicative of irritant contact cheilitis or atopic cheilitis but because of the multiplicity of factors causing lip inflammation, differential diagnosis of eczematous cheilitis is somewhat difficult.[symptoma.com]
  • The main cause of endogenous eczematous cheilitis is atopic cheilitis ( atopic dermatitis ), and the main causes of exogenous eczematous cheilitis is irritant contact cheilitis ( e.g. , caused by a lip-licking habit) and allergic contact cheilitis.[en.wikipedia.org]
  • While one of the more common side-effects is cheilitis, we have observed an increased incidence of cheilitis prior to the commencement of systemic isotretinoin.[ncbi.nlm.nih.gov]
  • Histologically, of the 33 cases with AP cheilitis with cutaneous lesions, 17 (52%) cases showed follicular cheilitis, and of the 42 cases that had only lip lesions, 18 (43%) cases showed follicular cheilitis.[ncbi.nlm.nih.gov]
  • The cell proliferation index was higher in actinic cheilitis with dysplasia and lip squamous cell carcinoma than in actinic cheilitis without epithelial dysplasia.[ncbi.nlm.nih.gov]
Cracked Lips
  • Frequent application of moisturizing creams can help soothe dry and cracked lips. Prescription A doctor may prescribe topical antibiotics to treat cheiltis.[dermapproved.com]
  • Cheilitis is commonly known as cracked lips or sometimes known as chapped lips. Lips being very insightful, cracking of them can be very uncomfortable for us.[findhomeremedy.com]
  • Wind, cold , and sun exposure are common environmental causes of cracked lips. Drug reactions, skin diseases, and other conditions can also cause inflammation of the lips.[medicinenet.com]
  • But, the first sign is cracked lips.[bluemcare.com]
Lip Swelling
  • CG should be considered in the differential of persistent lip swelling.[ncbi.nlm.nih.gov]
  • Thus, Facescan 3D facial reconstruction technology showed good reproducibility in the evaluation of lip swelling in CG patients, and it can be used to analyse the degree of lip swelling and evaluate the therapeutic efficacy of different treatments for[ncbi.nlm.nih.gov]
  • Cheilitis granulomatosa is characterized by granulomatous lip swelling.[ncbi.nlm.nih.gov]
  • The correct diagnosis is orofacial granulomatosis, a rare chronic inflammatory disease characterised by relapsing/remitting lip swelling. It can also involve the buccal mucosa, gingivae and floor of the mouth.[medicinetoday.com.au]
Excoriation
  • Over a quarter (27%) of patients with cheilitis had acne excorie, compared with only 8% of patients with no signs of cheilitis. Our findings suggest that cheilitis is quite common among acne vulgaris patients even before treatment with isotretinoin.[ncbi.nlm.nih.gov]
Leukonychia
  • Here we show that loss-of-function mutations in calpastatin (CAST) are the genetic causes of an autosomal-recessive condition characterized by generalized peeling skin, leukonychia, acral punctate keratoses, cheilitis, and knuckle pads, which we propose[ncbi.nlm.nih.gov]

Workup

Eczematous cheilitis

Patient evaluation involves: 

  • Thorough oral examination for signs of atopy or other manifestations of dermal pathology affecting the  lips. 
  • Personal and family history-taking with reference to atopic diseases.
  • History of contact with irritants or allergens (e.g., foods, cosmetics, plants, fomites, sunscreens, pets, metals, dental products).
  • Patch test

Patch test uses a standard set of known and suspected allergens (including the patient's personal effects). A positive patch test is indicative of irritant contact cheilitis or atopic cheilitis but because  of the multiplicity of factors causing lip inflammation, differential diagnosis of eczematous cheilitis is somewhat difficult. 

Actinic cheilitis

This type of cheilitis is usually diagnosed on the basis of its unique clinical features such as the predilection for the lower lips of older light-skinned individuals with excessive exposure to the sun. The occurrence of ulceration or erosion warrants the need for for histopathologic examination to rule out squamous cell carcinoma. The histology shows focal areas of  atrophy, acanthosis, hyperkeratosis and atypical keratinocytes [24].

Angular cheilitis

Diagnosis is unequivocal, given that microscopic examination of swab from lesions and oral mucosa, can confirm or rule out bacterial and/or fungal infections. 

Plasma cell cheilitis

Lip biopsy examination will show the upper dermis with a dense band-like lichenoid infiltrate made up of mature plasma cells [16] [19] [20]. 

Cheilitis granulomatosa

Lip biopsy should reveal evidence of granulomatous inflammation, edema, perivascular infiltrate of plasma cells and lymphocytes and dilatation of lymphatic vessels. 

Anisocytosis
  • Anisonucleosis (P 0.0001), nuclear pleomorphism (P 0.0001), anisocytosis (P 0.03), cell pleomorphism (P 0.002) increased nuclear/cytoplasm ratio (P 0.0001), increased nuclear size (P 0.0001), increased number of mitotic figures (P 0.0006), and dyskeratosis[ncbi.nlm.nih.gov]

Treatment

Eczematous cheilitis

  • Avoidance of contact with known and suspected irritants or allergens (from the results of patch test). If possible at all, require complete removal of these causative agents from the patient's environment.
  • Use of topical corticosteroids with emollients (petrolatum) to alleviate symptoms of inflammation and pruritus, b.i.d. 1-2 weeks.

Actinic cheilitis

  • Treatment options include destructive therapies (e.g., liquid nitrogen, dermabrasion, photodynamic therapy), topical medications (e.g, fluorouracil, retinoids), and surgery (vermilionectomy) [1].

Depending upon the patient's status and the physician's discretion, the following treatment modalities are recommended:

  • For mild to moderate actinic cheilitis, isolated lesions, cryotherapy with liquid nitrogen is indicated. For multiple or dispersed lesions - topical fluorouracil or imiquimod,
  • Ddiclofenac 3% gel, less irritating side effect than topical fluorouracil or imiquimod, but requires several months of treatment [25] [26].
  • For severe actinic cheilitis and refractory patients (to topical treatments), with diffuse mild to moderate cheilitis to topical treatments, abalation of lesions with carbon dioxide (CO2) laser or erbium:yttrium aluminum-garnet (Er:YAG) laser.
  • For severe actinic cheilitis with dysplasia vermilionectomy and primary closure or placement of mucosal advancement flap for damage repair should be considered.

Angular cheilitis

  • The main approach to management is that of controlling salivation at the corners of the mouth which promotes microbial (bacterial and fungal) growth and prescribing specific antimicrobial therapy. Other helpful measures are: ensuring denture fit, oral hygiene, treating sicca and use of barrier creams (e.g., zinc oxide paste) or petrolatum.
  • Topical mycotic therapy for patients with positive KOH preparation: Azole (e.g., clotrimazole, miconazole) ointment, b.i.d. 1-3 weeks, repeat as needed.
  • For cleared lesions nightly application of a barrier cream or petrolatum to prevent recurrence is advised [27].

Plasma cell cheilitis

  • Highly potent topical and intralesional corticosteroids. Variable results [19].
  • Other medications - topical calcineurin inhibitors [16], topical antibiotics, topical cyclosporine, oral griseofulvin, and excimer laser therapy.

Cheilitis glandularis

  • Sytemic antibiotics
  • Systemic, intralesional, or topical corticosteroids
  • Surgical of the vermilion [1] [2], few documented cases.

Cheilitis granulomatosa

  • Radical treatment needed, rarely attended by complete remission.
  • Monotherapy/multiple therapies with systemic, intralesional and topical corticosteroids [28] [29], antibiotics (metronidazole, minocycline, roxithromycin); others (dapsone, clofazimine, thalidomide).
  • Surgery and anti-TNF agents.

Prognosis

Actinic cheilitis and actinic keratosis have a common morbidity profile, with the exception that the risk of squamous cell carcinoma (SCC) is considered higher in actinic cheilitis. [21].

Etiology

  • Factors associated with eczematous cheilitis are of endogenous (eg. atopic dermatitis) or exogenous (contact irritants or allergens) etiology, or a combination of these [5] in some patients. 
  • Irritant contact cheilitis is the most common type of lip disorder [1] [6] [7], mainly due to lip-licking especially in young children. 
  • Allergic contact cheilitis is characterized by a delayed-type hypersensitivity reaction to allergens, particularly among women following contact with makeup products, lipstick, lip balm, nail polish and sunscreen [5] [7] [8] [9]. Other allergens may be acquired from oral hygiene products (toothpaste, mouthwash) and foods (cinnamon, citrus, mango).
  • Atopic cheilitis is seen in patients with a history of atopy such as atopic dermatitis
  • Actinic or solar cheilitis is a premalignant keratosis of the lip caused by persistent exposure to the sun [1] [10] [11]. The disorder commonly occurs in hot dry areas. Associated host factors are: occupation (outdoor workers), complexion (light or fair), age (older persons), sex (males), smoking (tobacco use), and heredity (increased vulnerability to UVL radiation from the sun). 
  • Angular cheilitis is associated with maceration of labial tissues from saliva and secondary microbial infection (C. albicans, S. aureus) [12] [13], from habitual thumb-sucking, drooling and lip-licking among children [12] [14] [15]. Other predisposing conditions in others are malnutrition, type 2 diabetes mellitus, immune deficiency, adverse reactions to oral hygiene or dental products and drugs causing dryness and xerostomia.
  • Cheilitis glandularis has an unknown etiology but chronic sun exposure, atopy, factitial cheilitis, infection and tobacco use appear involved.
  • Cheilitis granulomatosa has been seen in siblings in Melkersson-Rosenthal syndrome and otherwise unaffected relatives may have the plicated tongue trait as well. The etiology is unknown, predisposing factors (allergens from foods, heredity, infection, atopy) have been implicated. 

Epidemiology

Angular cheilitis occurs in both male and female of all ages. Older individuals are particularly vulnerable from wearing of orthodontic devises or ill-fitting dentures. Other predisposing factors include: siccus (dry mouth), poor oral hygiene; microbial infection and anatomical changes with age [12] [14] [15]. Cheilitis glandularis affects older males, women and young persons in general. Cheilitis granulomatosa is rare seen if at all in young adults (male and female), without age differences.

Sex distribution
Age distribution

Pathophysiology

Actinic cheilitis: Characteristic histology shows evidence of acanthosis, hyperkeratosis, atrophy, abnormal keratinocytes, and inflammatory infiltrate consisting of numerous lymphocytes and few plasma cells and eosinophils.

Plasma cell cheilitis: Resembles the typical features of Zoon's erythroplasia (balanitis) and similar lesions of other mucosal sites (oral, upper respiratory tract, vulva) [16] [17] [18]. The upper dermis shows a dense band-like lichenoid infiltrate of mature plasma cells [16] [19] [20]. Other pathognomonic signs are extravasation, capillary dilatation, hemosiderin deposits, and epidermal edema.

Cheilitis glandularis: Histopathology shows hyperplasia of salivary gland, duct ectasia (dilatation) and an inflammatory infiltrate of plasma cells, lymphocytes and macrophages.

Cheilitis granulomatosa: Recognized by the presence of small, non-caseating and dispersed granulomas with giant Langerhans cells, edema, inflammation, cellular infiltrate of lymphocytes and plasma cells and dilatation of lymphatic vessels (lymphangiectasia). 

Prevention

Prevention of actinic cheilitis includes:

  • Avoidance of solar (ULV) exposure is of vital importance in preventing exacerbation of actinic cheilitis and the potential for developing into squamous cell carcinoma
  • Personal protection measures include wearing of hats and use of lip cosmetics with sunscreens [30].

Prevention in angular cheilitis includes:

  • Healthy diet while avoiding junk food (usually with preservatives and adjuvants).
  • Minimizing exposure to sun and rain.
  • Awareness and avoidance of other environmental pollutants.
  • Drinking adequate amounts of water and fluids daily.
  • Eliminating the habit of licking or biting of lips.
  • Practicing oral and dental hygiene, exfoliation (hair removal), and moistening the lips in moderation.

Summary

Cheilitis is basically an acute or chronic inflammation of the lips. It involves the lip vermilion (red part of the lip), its border and adjacent facial skin, including the oral mucosa [1]. Among the endogenous and exogenous causative factors are infection, solar exposure, atopic dermatitis, contact dermatitis, allergens, bad denture, immunosuppression and certain habits. Cutaneous and systemic disorders, autoimmune diseases, sarcoidosis, Crohn disease, and nutritional deficiencies are likewise involved.

Types of cheilitis and their distinctive features:

  • Eczematous cheilitis: The most common lip disorder seen especially in young children and women with chief complains of inflammation, chaffing, dryness, itchiness, burning sensation, cracks and redness of the affected area, including the perioral skin and oral mucosa.
  • Actinic cheilitis: Occurs in fair-skinned persons more than 40 years old with a history of chronic exposure to the sun. Considered as a precancerous stage of keratosis of the lip.
  • Angular cheilitis (perleche or commissural cheilitis): As the name implies, characterized by inflammation of the skin at one or both corners of the mouth and extending to the labial mucosa.
  • Plasma cell cheilitis: Associated with sharply defined or flawed, flat and hardened reddish plaques present mostly on the lower lip; so far, a rare benign lip disorder.
  • Cheilitis glandularis: Chronic inflammatory involvement of the salivary glands of the lower lip. Uncommon if at all seen in older males, also in younger persons and women [2] [3]. Etiology remains unknown although prolonged sun exposure, infection, atopy, tobacco use and idiopathic factors have been suspected.
  • Cheilitis granulomatosa (Miescher’s cheilitis): Recurrent idiopathic swelling of the lips [4], considered to be part of orofacial granulomatosis (OFG). The latter is associated with long-standing soft tissue enlargement ulceration and various orofacial manifestations, in the absence of Crohn disease or sarcoidosis.

Patient Information

General information on cheilitis:

  • Cheilitis is a condition of the lips whereby on-going and long-standing inflammatory processes are involved causing potential hazards to health.
  • The principal affected areas are the lip vermilion (the red part of the lips), the facial skin adjacent to the vermillion (vermillion border) and the buccal (oral) mucosa.
  • Symptoms vary according to the specific type of cheilosis and certain host or environmental factors.
  • Habits such as licking or biting the lips and rubbing the surrounding areas irritate these parts and promote the development of cheilitis.
  • Moisture lodged in the skin folds at the corner of the mouth provides a rich "culture medium" for the growth of disease, causing microorganisms (fungal and bacterial pathogens) such as Candida and Staphyloccocus).

Types of cheilitis:

  • Cheilitis eczematoza is the most common type of lip disease. The manifestations are pruritus (itching), dryness, burning sensation, scaling, erythema (reddening) and fissuring (breaks) on the lips. The perioral (skin around the mouth) and the oral mucosa are likewise affected.
  • Actinic cheilitis (premalignant keratosis of the lip), is among fair-skinned individuals (40 and above) with history of chronic exposure to the sun.
  • Angular cheilitis (perleche) is an inflammation of the skin and adjoining labial mucosa located at the lateral commissures (corners) of the mouth

What to expect upon consultation for cheilitis:

  • The physician will check your dentures, if any, to assure that they are properly installed.
  • You will be asked about certain personal habits relating to oral care, medications, use of cosmetics, diet, exposure to the sun and sometimes relevant family history of allergy.
  • Blood tests may be requested to test for immune deficiency and anemia and a smear from the lesions may be taken for microbiological examination.
  • You will be advised to avoid licking or biting your lips, or rubbing the corners of your mouth, to wear a hat and to use lip cosmetics against exposure to the sun.
  • The goal of treatment and prevention is to alleviate symptoms, to eliminate the causes and to cultivate healthy habits.
  • Steroids, antifungal or antibacterial medications will be prescribed against infection.
  • Other specialized examinations may be needed upon the discretion of the attending physician.
  • Otherwise, prognosis is good once the prediposing factors have been dealt with.

References

Article

  1. Rogers RS 3rd, Bekic M. Diseases of the lips. Semin Cutan Med Surg. 1997; 16:328. 
  2. Carrington PR, Horn TD. Cheilitis glandularis: a clinical marker for both malignancy and/or severe inflammatory disease of the oral cavity. J Am Acad Dermatol. 2006; 54:336. 
  3. Andrade ES, Sobral AP, Laureano Filho JR, et al. Cheilitis glandularis and actinic cheilitis: differential diagnoses - report of three unusual cases. Dermatol Online J. 2009; 15(1):5. 
  4. Critchlow WA, Chang D. Cheilitis granulomatosa: a review. Head Neck Pathol. 2014; 8:209. 
  5. Lim SW, Goh CL. Epidemiology of eczematous cheilitis at a tertiary dermatological referral centre in Singapore. Contact Dermatitis. 2000; 43:322. 
  6. Zug KA, Kornik R, Belsito DV, et al. Patch-testing North American lip dermatitis patients: data from the North American Contact Dermatitis Group, 2001 to 2004. Dermatitis. 2008; 19:202. 
  7. Zoli V, Silvani S, Vincenzi C, Tosti A. Allergic contact cheilitis. Contact Dermatitis. 2006; 54:296. 
  8. Rademaker M. Adverse effects of isotretinoin: A retrospective review of 1743 patients started on isotretinoin. Australas J Dermatol. 2010; 51:248. 
  9. Freeman S, Stephens R. Cheilitis: analysis of 75 cases referred to a contact dermatitis clinic. Am J Contact Dermat. 1999; 10:198. 
  10. Savage NW, McKay C, Faulkner C. Actinic cheilitis in dental practice. Aust Dent J. 2010; 55 Suppl 1:78. 
  11. Jadotte YT, Schwartz RA. Solar cheilosis: an ominous precursor: part I. Diagnostic insights. J Am Acad Dermatol. 2012; 66:173. 
  12. Park KK, Brodell RT, Helms SE. Angular cheilitis, part 1: local etiologies. Cutis. 2011; 87:289. 
  13. Terai H, Shimahara M. Cheilitis as a variation of Candida-associated lesions. Oral Dis. 2006; 12:349. 
  14. Cross DL, Short LJ. Angular cheilitis occurring during orthodontic treatment: a case series. J Orthod. 2008; 35:229. 
  15. Sharon V, Fazel N. Oral candidiasis and angular cheilitis. Dermatol Ther. 2010; 23:230. 
  16. Hanami Y, Motoki Y, Yamamoto T. Successful treatment of plasma cell cheilitis with topical tacrolimus: report of two cases. Dermatol Online J. 2011; 17:6. 
  17. Bharti R, Smith DR. Mucous membrane plasmacytosis: a case report and review of the literature. Dermatol Online J. 2003; 9:15. 
  18. White JW Jr, Olsen KD, Banks PM. Plasma cell orificial mucositis. Report of a case and review of the literature. Arch Dermatol. 1986; 122:1321. 
  19. Yang JH, Lee UH, Jang SJ, Choi JC. Plasma cell cheilitis treated with intralesional injection of corticosteroids. J Dermatol. 2005; 32:987. 
  20. Tamaki K, Osada A, Tsukamoto K, et al. Treatment of plasma cell cheilitis with griseofulvin. J Am Acad Dermatol. 1994; 30:789. 
  21. Jadotte YT, Schwartz RA. Solar cheilosis: an ominous precursor: part I. Diagnostic insights. J Am Acad Dermatol. 2012; 66:173. 
  22. Kaugars GE, Pillion T, Svirsky JA, et al. Actinic cheilitis: a review of 152 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999; 88:181. 
  23. Elias MK, Mateen FJ, Weiler CR. The Melkersson-Rosenthal syndrome: a retrospective study of biopsied cases. J Neurol. 2013; 260:138. 
  24. Vieira RA, Minicucci EM, Marques ME, Marques SA. Actinic cheilitis and squamous cell carcinoma of the lip: clinical, histopathological and immunogenetic aspects. An Bras Dermatol. 2012; 87:105.
  25. Ulrich C, Forschner T, Ulrich M, et al. Management of actinic cheilitis using diclofenac 3% gel: a report of six cases. Br J Dermatol. 2007; 156 Suppl 3:43.
  26. Lima Gda S, Silva GF, Gomes AP, et al. Diclofenac in hyaluronic acid gel: an alternative treatment for actinic cheilitis. J Appl Oral Sci. 2010; 18:533. 
  27. Ohman SC, Jontell M, Dahlen G. Recurrence of angular cheilitis. Scand J Dent Res. 1988; 96:360. 
  28. Bacci C, Valente ML. Successful treatment of cheilitis granulomatosa with intralesional injection of triamcinolone. J Eur Acad Dermatol Venereol. 2010; 24:363. 
  29. Mignogna MD, Fedele S, Lo Russo L, et al. Effectiveness of small-volume, intralesional, delayed-release triamcinolone injections in orofacial granulomatosis: a pilot study. J Am Acad Dermatol. 2004; 51:265 
  30. Cavalcante AS, Anbinder AL, Carvalho YR. Actinic cheilitis: clinical and histological features. J Oral Maxillofac Surg. 2008; 66:498.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2017-08-09 18:05