Tutorial presentation

Cheilitis

Presenter:- Dr. Pradeep Garg

• Synonym- Inflammation of the lips• May arise as a • Primary disorder of the vermilion zone or • Inflammation may extend from nearby skin or, • Less often, from the oral mucosa

Causes of cheilitis.

Chapping due to cold and wind Actinic prurigo of the lip

Eczematous cheilitis Glandular cheilitis

Contact cheilitis Granulomatous cheilitis

Drug-induced cheilitis Exfoliative (factitious) cheilitis

Infective cheilitis Plasma cell cheilitis

Angular cheilitis Nutritional cheilitis

Ultraviolet irradiation Dermatoses

Actinic cheilitis Trauma

‘Chapping’ of the lips

• Reaction to adverse environmental conditions

• Caused by exposure to freezing cold or to hot dry winds.

• Keratin of the vermilion loses its plasticity, so that the lips become sore, cracked and scaly.

• Affected person tends to lick the lips, or to pick at the scales, which may aggravate the condition.

• Treatment- Petroleum jelly and avoidance of the adverse environmental conditions

Eczematous cheilitis

• Presenting as redness with dryness, scaling and fissuring.

• Major causes- atopic dermatitis and irritant or allergic contact reactions

• Treatment- Emollients and topical corticosteroids.

• A potent steroid may be required to bring the condition under control

Contact cheilitis

• F>M• Affect all age groups, but adults>children. • Lip cosmetics are the most common allergen source in

women, and toothpastes in men. • Medications in the elderly. • Dental materials and oral hygiene products in all age

groups. • Reactions to food mainly affect children. • Patients are often also atopic.

• Major sources of allergens :• Lipsticks and other lip cosmetics including sunscreens• Toothpaste and other dental care products (mouthwash,

denture cleaner, dental floss, toothpicks)• Metals – dental restorations, orthodontic devices, musical

instruments, metal casings of lip cosmetics, habitual sucking of metal objects

• Food, Medications, Nail varnishes• Rubber/latex gloves• Common allergen groups:• Metals such as nickel• Fragrance/Flavourings and Preservatives

• C/f- Lipstick cheilitis may confined to the vermilion or extends beyond.

• Persistent irritation and scaling or a more acute reaction with oedema and vesiculation.

• Other forms of cheilitis vary greatly in their clinical appearance.

• Foods commonly also involve the skin around the mouth. • If a small, sucked object is responsible, the reaction may be

confined to one part of the lips

• Diagnosis- If acute eczematous changes- contact cheilitis . • If the changes are confined to irritation and scaling-

exfoliative cheilitis must be excluded.• If an allergic reaction is suspected, patch tests should be

carried out.• Treatment- Topical corticosteroids will give symptomatic

relief but the offending substance must be identified and avoided

Infective cheilitis

• Viral- HSV are common, and VZV and HPV may also affect the lips.

• Bacterial- Dental infection or occasionally a furuncle or carbuncle may cause swelling of the lip.

• Impetigo may mimic herpes labialis. • Lip is the MC extragenital site for a primary syphilitic lesion. • Most lip chancres in males tend to occur on the upper lip,

in females on the lower lip.

• In secondary syphilis, moist, flat, papulonodular lesions (condylomata lata) often appear at the mucocutaneous junctions and commissures.

• TB or leprosy may cause chronic lip swelling or ulceration• Rhinoscleroma initially affects the nasal mucosa but may

spread slowly to the upper lip, producing plaques or nodules with sunken centres.

• Extreme hardness of the infiltrations is characteristic.

• Protozoal- Cutaneous or mucocutaneous leishmaniasis typically causes swellings on the upper lip with later enlargement and destruction of the lip, reflecting the three stages of oedema, granulomatous proliferation and then necrosis.

• Fungal- Blastomycosis and paracoccidioidomycosis are uncommon causes of chronic ulceration affecting the lip, producing very similar clinical lesions to leishmaniasis.

• Others- Red swollen lips with fissuring and exfoliation are prominent in mucocutaneous lymph node syndrome (Kawasaki disease).

Angular cheilitisSynonym-Angular stomatitis

• Acute or chronic inflammation of the skin and contiguous labial mucous membrane at the angles of the mouth.

• Aetiology-• Dribble of saliva causing eczematous cheiltiis, a form

of contact irritant dermatitis• Overhang of upper lip resulting in deep furrows (marionette

lines)• Dry chapped lips• Proliferation of bacteria (impetigo), yeasts (thrush) or virus

(cold sores)

• Affects children and adults, in poor health. • Predisposing factors include:• Oral thrush: infancy, old age, diabetes, systemic

corticosteroid or antibiotic use• Dentures, especially if they are poor fitting, and there is

associated gum recession• Poor nutrition: coeliac disease, iron deficiency, riboflavin

deficiency• Systemic illness, particularly IBD (ulcerative colitis

and Crohn disease)• Sensitive skin, especially atopic dermatitis• Genetic predisposition, for example in Down syndrome• Oral retinoid

• C/f- • Painful cracks / fissures• Blisters / erosions / ooze / crusting• Redness, Bleeding• It may progress to more widespread impetigo or candidal

skin infection on the adjacent skin and elsewhere.• Investigations• Culture of swabs taken from the corners of the mouth may

reveal:• Candida albicans• Staphylococcus aureus• Herpes simplex

Angular cheilitis

• Treatment-• Lip balm or thick emollient ointment, applied frequently• Topical antiseptics• Topical or oral antibiotic• Topical antifungal cream• Oral antifungal medication• Topical steroid ointment• Nutritional supplements• Filler injections or implants to build up the oral

commissures

Actinic cheilitis

• Synonyms-Actinic keratosis of lip • Solar cheilosis • Aetiology- MC in hot dry regions, in outdoor workers and in

fair-skinned people (skin types I and II).• Vermilion of the lower lip receives a high dose of UV

irradiation because it is almost at right angles to the rays of the midday sun and is poorly protected by keratin and melanocytes.

• C/f- Dry lips, Thinned skin of the lips, Scaly patches• Less common features:• Swelling of the lip• Redness and soreness, Ulceration and crusting• Loss of demarcation between the vermilion border of the

lip and its adjacent skin• Prominent folds and lip lines• White thickened patches (leukokeratosis)• Discoloured skin with pale or yellow areas

Chronic actinic cheilitis with leukoplakia actinic cheilitis

• Treatment- to relieve symptoms and to prevent development of SCC

• Topical agents: 5% fluorouracil TDS for 10 days is suitable. • Tretinoin, TCA or diclofenac gel may also be effective.• Vermilionectomy (lip shave).• Laser ablation.• Photodynamic therapy.• Following treatment, prevention of recurrence by the

regular use of a sunscreen lipsalve containing p-aminobenzoic acid probably gives the best protection.

Glandular cheilitis• Inflammatory changes and swelling of salivary glands in the

lips.• Aetiology- idiopathic, few cases familial. • Excessive salivary secretion from minor salivary glands, an

unusual clinical response to irritation of the lip from some other cause such as actinic damage or repeated licking.

• C/f- Lower lip is slightly thickened and bears numerous pinhead-sized orifices, from which mucous saliva can readily be squeezed.

• Upper lip is rarely involved• In the more severe suppurative form (Volkmann’s cheilitis) the

lip is considerably and permanently enlarged, and subject to episodes of pain, tenderness and increased enlargement.

• Surface is covered by crusts and scales, beneath which the salivary duct orifices may be discovered.

• In the most severe forms there may be deep-seated infection with abscess formation and fistulous tracts.

• In some series 20–30% of cases progress to SCC.

• In many cases it is a consequence of actinic cheilitis.

• T/t- If the lips are grossly enlarged, excision of an elongated ellipse of tissue may be required

Granulomatous cheilitis

• Lumpy swelling of the lips.• Different causes, such as allergy, Crohn disease, sarcoidosis

and orofacial granulomatosis.• Rare causes are infections, cancers and genetic disorders.• Miescher-Melkersson-Rosenthal syndrome refers to

recurrent chronic swelling and enlargement of one or both lips.

• Facial palsy and fissuring of the tongue may also occur. • Cause- not known, but genetics may have a role.• In Miescher cheilitis, the changes are confined to the lip. • First symptom is a sudden swelling of the upper lip.

• Swelling of the lower lip and one or both cheeks may follow in Melkersson-Rosenthal syndrome.

• Less commonly, the forehead, eyelids, or one side of the scalp may be involved.

• Swelling may feel soft, firm or nodular when touched.• Recurrent attacks may occur within days or even years after

the first episode. • At each episode the swelling may become larger, more

persistent and eventually become permanent. • At this time the lips may crack, bleed and heal leaving a

reddish-brown colour with scaling. This can be painful. • Eventually the lip takes on the consistency of hard rubber.

• Other symptoms include:• Fever, headache and visual disturbances• Mild enlargement of regional lymph nodes in 50% of cases.• Fissured or plicated tongue in 20-40% of cases.• Facial palsy; intermittent, then possibly permanent and can

be unilateral or bilateral, and partial or complete. • It occurs in about 30% of cases.• Skin biopsy of the affected tissue shows characteristic

granulomas i.e. a mixed inflammatory cell infiltration in the dermis.

Granulomatous cheilitis of the lower lip.

• Treatment- Reactions to dietary components should be sought and possible antigens avoided.

• Topical corticosteroids• Long term anti-inflammatory antibiotics e.g. a six to twelve

month course of tetracycline, erythromycin or penicillin• Corticosteroids injected into the lips to reduce swelling.

Injections need to be repeated every few months.• NSAIDS• Mast cell stabilisers eg ketotifen• Clofazimine• Sulfasalazine• Surgical reduction

Exfoliative cheilitis

• Presenting as continuous peeling of the lips.• Factitial- if the behaviour triggering the condition is

attention-seeking.• Exfoliative - obsessive-compulsive with no intent of gain.• Mainly affects young adults <30 years with personality

disorders.• Initiating factors include: Mouth breathing, Lip licking, Lip

sucking, Lip picking, Lip biting.• Poor oral hygiene, HIV infection and Candida.

• C/f- Continuous peeling of the vermilion of the lips. • Usually affect the lower lip.• Peeling appears to be cyclical and proceeds at different

rates in different sites, so there is always some part of the lip peeling at any time.

• There may be associated bleeding resulting in formation of a haemorrhagic crust.

• Condition may be painful, causing difficulty in eating and speaking.

• Other symptoms include sensations of: Tingling, Itch, Dryness, Ulceration or fissuring may occur

Factitious cheilitis due to repeated lip sucking

Exfoliative cheilitis

• Diagnosis- it is a diagnosis of exclusion and there is no specific diagnostic test for it.

• A careful psychiatric assessment can be especially helpful • Treatment- Some cases resolve spontaneously or with

improved oral hygiene. • Reassurance and topical corticosteroids, or tacrolimus may

be helpful in some cases but others require psychotherapy, antidepressants or tranquillizers.

Plasma cell cheilitis

• Uncommon chronic inflammatory dermatitis that presents with flat to slightly elevated erosive erythematous plaques.

• Genital areas are often involved, k/a plasma cell balanitis or vulvitis.

• Sometimes resistant to conventional topical corticosteroid therapy

• Recent reports show that topical calcineurin inhibitors are effective

Lupus erythematosus• Involvement of the vermilion zone

is quite common in both DLE and SLE.

• DLE can be premalignant, and should be treated vigorously with topical steroid ointments and sunscreens.

• Cheilitis of SLE more severe, with erosions and haemorrhagic crusts.

• Lupus erythematosus can be very difficult to distinguish from LP of the lips, both clinically and by histology

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• Possible fruit and vegetable allergens.

Apple Fennel Asparagus

Artichoke Carrot Cherry

Orange Peach Pear

Lime Parsley Onion

Garlic Parsnip Mango

Celery Potato Tomato

Pineapple Plum Banana

Miscellaneous objects-

Metal hair clips metal pencils

cobalt paint on blue pencils nail varnish

Wooden nickel and reed mouthpieces of musical instruments

Lipsticks and lipsalves

mineral oils and wax oleyl alcohol

castor oil azulene

lanolin sesame oil

preservatives, stearates

perfumes colophony

colours eosin

azo dyes Sunscreens (e.g. cinnamic aldehyde)

Mouthwashes and dentrifices, Dental preparations-

essential oils imonene

peppermint pinene

cinnamon phellandrene

spearmint linalool

carvone alcohol

• It is present from birth in some, which may indicate genetic susceptibility.

• There may be loss of sense of taste and decreased salivary gland secretion.

• Regional lymph nodes are enlarged in 50% of cases but not usually very greatly.

• Facial palsy of the lower motor neurone type occurs in some 30% of cases.

• It may precede the attacks of oedema by months or years, but more commonly develops later Although intermittent at first, the palsy may become permanent.

• It may be unilateral or bilateral, and partial or complete. • Other cranial nerves (olfactory, auditory, glossopharyngeal

and hypoglossal) may occasionally be involved. • Involvement of the CNS has also been reported, but the

significance of the resulting symptoms is easily overlooked as they are very variable, sometimes simulating disseminated sclerosis but often with a poorly defined association of psychotic and neurological features.

• Autonomic disturbances may occur.

• Diagnosis- Essential feature of the syndrome is the granulomatous swelling of lip or face.

• In the early attacks clinical differentiation from angio-oedema may be impossible in the absence of either scrotal tongue or facial palsy.

• Persistence of the swelling between attacks should suggest the diagnosis, which can sometimes be confirmed by biopsy.

• In established cases, other causes of macrocheilia must be excluded.

• Lymphoma is a rare differential diagnosis.

Actinic prurigo• Familial photodermatitis, Seen in High altitude especially in

Latin America, and in China.• Young women presents as a photosensitive facial rash with

pruritic lower lip cheilitis, • May be a/w conjunctivitis, eyebrow alopecia and pterygion.• Distinguished from actinic cheilitis, which is due to

prolonged and excessive exposure to UV irradiation. • PMLE is almost invariably present in the actinic prurigo of

native Americans.• Treatment- Sunscreens, β-carotene, PUVA, and

antihistamines. • Oral thalidomide may be tried