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Characterization and management of exfoliative cheilitis: A single-center experience
Abstract
Exfoliative cheilitis (EC) is a rare inflammatory condition affecting the vermilion of the lips and characterized by production of a thick keratin scale. Given the limited available data, the approach to optimal management of EC remains unclear. The objective of this retrospective study was to characterize the clinical features, management, and outcomes of a series of patients with EC. Fifteen patients with a median age of 59 years and a female-to-male ratio of 2:1 were diagnosed with EC from 2000 to 2010. Parafunctional lip licking (53%) and a history of psychiatric disorders (40%) were common. Ten patients (66%) returned for follow-up, with an overall response rate (partial or complete) of 80% at a median of 2 months, most frequently associated with the use of topical calcineurin inhibitors or moisturizing agents. Management of EC with topical calcineurin inhibitors and moisturizing agents is associated with clinical improvement, but prospective trials are needed.
... Exfoliative cheilitis (EC) is a rare and chronic inflammatory dermatological condition (7). It is characterized by a continuous peeling of the vermilion of the lips and abnormal production of keratin scales (8). ...
... Although the etiology is unknown, actinic damage, cold, wind, and/or nutritional deficiencies (iron and vitamin B12) are believed to play a role in the pathogenesis of EC (7). Likewise, a relationship with stressful situations or psychiatric conditions has been reported, most cases of EC occur when patients are not controlled with medication or therapy (14). ...
... Systemic treatments such as antidepressants, antifungals, and corticosteroids have had variable efficacy (7). However, it is not clear the efficacy associated with the antidepressant or if the improvement was due to the modification of parafunctional habits (14). ...
Exfoliative cheilitis (EC) is a rare and chronic inflammatory condition. It is characterized by a continuous peeling of the vermilion of the lips and abnormal production of keratin scales. Treatment is difficult due to its chronic nature and it is often refractory. The objective of this article is to describe the management of EC and its impact on quality of life through two clinical cases. Two patients with EC are reported: one 21 years old with allergic rhinitis and gastric reflux, the other 18 years old, with a history of anxiety symptoms, without medication or psychiatric control. They had chronic scaly and crusty areas on both lip vermilions. In one of the patients, a biopsy was prescribed and he was treated with antifungals and topical vitamin E. Both patients were prescribed hydration, balanced diet, the application of moisturizing lip balm with sunscreen and modification of parafunctional habits, behavioral aid. The treatment healed the condition and eased their daily life and improved personal perception. Nibbling and lip licking favor dryness and superinfection in patients with EC; for its part, hydration, topical vitamin E and behavioral aid, improved this condition.
... Th e term ch eilitis indicates infl ammation of the lip and includes many types, i.e. angular, contact, exfoliative, actinic, glandular, granulomatous, plasma cell cheilitis, simplex, etc. [1][2][3][4][5] . In practice, it is diffi cult to defi ne readily the precise type of cheilitis, thus proper diagnostic procedures are necessary to determine the exact disease based on its characteristics 5 . ...
... Sometimes bleeding occurs, later followed by the formation of a hemorrhagic crust. Th e disease may progress due to several factors, e.g., open-mouthed breathing, lip licking, sucking, picking, or biting, bacterial (Staphylococcus aureus) or yeast (Candida albicans) infection, poor oral hygiene, etc. 1 . Some use the term exfoliative cheilitis as an equivalent to cracked lips, which increases confusion around nomenclature. ...
... Diff erential diagnosis includes contact cheilitis, cheilitis simplex, etc. Th erapy includes topical corticosteroids, topical calcineurin inhibitor, topical Calendula offi cinalis L., and in some cases psychotherapy 1,18 . Occasionally, lesions resolve spontaneously. ...
Although cheilitis as a term describing lip inflammation has been identified and recognized for a long time, until now there have been no clear recommendations for its work-up and classification. The disease may appear as an isolated condition or as part of certain systemic diseases/conditions (such as anemia due to vitamin B12 or iron deficiency) or local infections (e.g., herpes and oral candidiasis). Cheilitis can also be a symptom of a contact reaction to an irritant or allergen, or may be provoked by sun exposure (actinic cheilitis) or drug intake, especially retinoids. Generally, the forms most commonly reported in the literature are angular, contact (allergic and irritant), actinic, glandular, granulomatous, exfoliative and plasma cell cheilitis. However, variable nomenclature is used and subtypes are grouped and named differently. According to our experience and clinical practice, we suggest classification based on primary differences in the duration and etiology of individual groups of cheilitis, as follows: 1) mainly reversible (simplex, angular/infective, contact/eczematous, exfoliative, drug-related); 2) mainly irreversible (actinic, granulomatous, glandular, plasma cell); and 3) cheilitis connected to dermatoses and systemic diseases (lupus, lichen planus, pemphi-gus/pemphigoid group, -angioedema, xerostomia, etc.).
... vitamin B12 deficiency, iron deficiency) are thought to play roles in the pathogenesis. 2,9 Factitial Cheilitis Factitial cheilitis is caused by repetitive behaviors such as lip-licking, sucking, biting, or picking and leads to a cyclic peeling of excess keratin. The diagnosis of factitial cheilitis is one of exclusion, as the clinical and histological presentation is relatively non-specific. ...
... 11 Ingredients reported to be helpful in soothing lips include ceramides, dimethicone, petrolatum, and shea butter. 9 In patients who are predisposed to dry lips (i.e. patients living in dry climates, persons exposed during winter months, and those with a history of atopic dermatitis, etc.), it is recommended to preventatively apply a bland lip balm multiple times per day, including before bed. ...
Dry, cracked lips are a common occurrence in both cold winter months and arid climates, leading many patients to experience discomfort year-round. Lip-licking, a compensatory measure, perpetuates the condition and often leads to lip-licking dermatitis. In patients in whom this compensatory measure becomes a chronic habit, other sequelae such as irritant contact dermatitis, cheilitis simplex, angular cheilitis, factitial cheilitis, secondary infections, and exfoliative cheilitis can arise. Given the high prevalence of lip-licking and subsequent dermatitis, it is important to counsel patients on interventions to prevent associated dermatitis and treatment methods to alleviate symptoms. Practical interventions in a daily routine should include application of a bland lip balm with ultraviolet protection, adequate hydration, protection of the lips from harsh weather conditions, and recognizing when dermatitis is present and further dermatologic care is indicated.
... Ten patients (66%) returned for followup examination with an overall convalescence rate (partial or complete) of 80% at a median follow-up time of 2 months, this was associated with the use of topical calcineurin inhibitors or moisturizers. Treatment of exfoliative cheilitis with topical calcineurin inhibitors and moisturizers is associated with improved clinical outcome, but further studies are needed to confirm their clinical outcome 21 . ...
The purpose of this review article is to determine the frequency of occurrence due to comorbidities, as well as age-related features.
In the course of a systematic review of the literature, information was searched in Russian and English without time limits in the PubMed electronic database, GoogleScholar, Cyberleninka and in the literature lists of relevant studies and reviews. Full-text articles were selected that describes the incidence of exfoliative cheilitis in age groups; associated with various labor activities of patients, as well as in regions with a high prevalence of OCM diseases
Included publications contained a description of this disease with clinical cases.
The review reviewed 123 articles. After analyzing the literature according to the inclusion criteria, the total number of included publications was 23 publications.
According to the studied literature, it can be assumed that exfoliative cheilitis is a fairly common disease in modern day-today dental practice and has a diverse etiology, therefore, the correct algorithm for primary diagnosis and routing of patients contributes to the formation of a correct clinical diagnosis.
... Some of them have less clinical significance being asymptomatic like morphological alterations while others have great clinical significance like lip lesions and developmental or congenital defects 2,3 . Lip anomalies are also associated with other syndromes as well like Melkerson-Rosentheal syndrome, Down syndrome etc. 4,5 The purpose of this study is to find out the prevalence of various lip anomalies found in adult population of central Punjab. Lip pits: Lip pits are developmental defects or depressions found at the upper or lower lip. ...
Aim: To find out the prevalence of various commonly occurring lip anomalies like lip fissures, angular chielitis, lip pits and allergic cheilitis in patients visiting out-patient clinic in central Punjab. Methods: This is a prospective observational study conducted at the diagnostics department of Nishter institute of dentistry, Multan from Feb,2022 to December,2022 for a period of 11 months to determine the relative frequency of various lip anomalies in adult population of central Punjab. Six hundred patients were examined with an age range of 25-35 years in a quite comfortable environment using dental mirror, natural light and surgical gauze. The result was analyzed by using chi-square test in SPSS. Results: The prevalence of lip anomalies in 600 patients was 24.3% among male and female patients. These lesions were more prevalent in patients of 25 to 30 years of age (55.47%) compared to 30-35 years of age (44.52%). Among lip lesions, lip fissures were seen in 7.4% cases, lip pits were 2.6%, allergic chielitis was seen 1.8% and patients with angular chielitis were 12.4%. All lesions showed almost equal distribution among male and female patients seen during the study. Practical Implication: Our study was done in central Punjab region. It highlighted the commonly occurring lesions of lip which could affect the aesthetics of the people as well as has important psychological impact on their daily life. Our study showed the prevalence of lesions and also motivated the people to seek possible treatment of the lesions. It helped a lot to educate affected community and encouraged them to improve their conditions. Conclusion: The results of the study are in accordance with some previous studies although they contradict to some other studies as well. This study has also shown that the lip anomalies are slightly more in females as compared to the males although the statistical difference is not significant. Moreover, the age is not related to the lip anomalies. Keywords: Lip anomalies, Lip fissures, angular chielitis, allergic chielitis, lip pits.
... Now, our recent research results concerning undesirable habits has found positive associations between lip licking or biting and exfoliative cheilitis [37]. According to other literature data, among subjects with exfoliative cheilitis, mainly female, the main undesirable habit was lip licking (53%), and 40% of the patients had a history of a mental disorder [42]. ...
Lip inflammation may manifest as mainly reversible cheilitis, mainly irreversible, or cheilitis connected to dermatoses or systemic diseases. Therefore, knowing a patient’s medical history is important, especially whether their lip lesions are temporary, recurrent, or persistent. Sometimes temporary contributing factors, such as climate and weather conditions, can be identified and avoided—exposure to extreme weather conditions (e.g., dry, hot, or windy climates) may cause or trigger lip inflammation. Emotional and psychological stress are also mentioned in the etiology of some lip inflammations (e.g., exfoliative cheilitis) and may be associated with nervous habits such as lip licking. To better manage cheilitis, it is also helpful to look for potential concomitant comorbidities and the presence of related diseases/conditions. Some forms of cheilitis accompany dermatologic or systemic diseases (lichen, pemphigus or pemphigoid, erythema multiforme, lupus, angioedema, xerostomia, etc.) that should be uncovered. Occasionally, lip lesions are persistent and involve histological changes: actinic cheilitis, granulomatous cheilitis, glandular cheilitis, and plasmacellular cheilitis. Perioral skin inflammation with simultaneous perioral dermatitis can have various causes: the use of corticosteroids and cosmetics, dysfunction of the skin’s epidermal barrier, a contact reaction to allergens or irritants (e.g., toothpaste, dental fillings), microorganisms (e.g., Demodex spp., Candida albicans, fusiform bacteria), hormonal changes, or an atopic predisposition. Epidermal barrier dysfunction can worsen perioral dermatitis lesions and can also be related to secondary vitamin or mineral deficiencies (e.g., zinc deficiency), occlusive emollient use, sunscreen use, or excessive exposure to environmental factors such as heat, wind, and ultraviolet light. Current trends in research are uncovering valuable information concerning the skin microbiome and disruption of the epidermal barrier of persons suffering from perioral dermatitis. Ultimately, an effective approach to patient management must take all these factors and new research into account.
... Lip inflammation is called cheilitis, which includes angular, contact, exfoliative, actinic, glandular, granulomatous, plasma cell, and simplex cheilitis, among others [41][42][43]. It is difficult to readily define the precise type of cheilitis [44]. ...
Oral and perioral soft tissues cooperate with other oral and pharyngeal organs to facilitate mastication and swallowing. It is essential for these tissues to maintain their morphology for efficient function. Recently, it was reported that the morphology of oral and perioral soft tissue can be altered by aging or orthodontic treatment. However, it remains unclear whether tooth loss can alter these tissues’ morphology. This study examined whether tooth loss could alter lip morphology. First, an analysis of human anatomy suggested that tooth loss altered lip morphology. Next, a murine model of tooth loss was established by extracting an incisor; micro-computed tomography revealed that a new bone replaced the extraction socket. Body weight was significantly lower in the tooth loss (UH) group than in the non-extraction control (NH) group. The upper lip showed a greater degree of morphological variation in the UH group. Proteomic analysis and immunohistochemical staining of the upper lip illustrated that S100A8/9 expression was higher in the UH group, suggesting that tooth loss induced lip inflammation. Finally, soft-diet feeding improved lip deformity associated with tooth loss, but not inflammation. Therefore, soft-diet feeding is essential for preventing lip morphological changes after tooth loss.
... La lesión se localiza esencialmente en el bermellón de los labios, en respuesta a la acción de irritantes externos de acción local que actúan por un mecanismo de hipersensibilidad13,14 . Estas noxas pueden ser de origen físico o químico e inician un proceso inflamatorio que se presenta como un eritema acompañado de aumento de tamaño y eversión labial en algunos casos, que posteriormente se fisura y se extiende a la piel15, 16. ...
p>Las queilitis por contacto son procesos patológicos de etiología multifactorial de origen externo que generan lesiones en el bermellón de los labios, en algunos casos se acompaña por una dermatitis contigua. Este tipo de queilitis recibe esta denominación debido al mecanismo de acción de la noxa productora, la cual actúa por contacto en la superficie labial produciendo una reacción antígeno anticuerpo. Los agentes sensibilizantes y desencadenantes del proceso inflamatorio son de origen físico y químico en sus diversas formas. Los físicos son los rayos actínicos y ultravioletas. Los químicos son más numerosos, como los cosméticos, alimentos, pastas y cepillos dentales. La incidencia es alta en el sexo femenino y en el labio inferior por su mayor superficie. El objetivo de este estudio fue realizar una evaluación comparativa de la crema de propóleos en el tratamiento de las queilitis por contacto y de la posible reacción adversa medicamentosa. Se llevó a cabo en pacientes de ambos sexos, a partir de los 15 años con diagnóstico clínico de queilitis por contacto, los que fueron asignados en forma aleatorizada simple en dos grupos. El primer grupo de control, recibió tratamiento tradicional. El segundo grupo experimental recibió la formulación objeto de estudio, la crema de propóleos. Ambas medicaciones redujeron de manera significativa la intensidad de la sintomatología y los signos sin efectos adversos en pacientes con queilitis por contacto. La formulación magistral de crema de propóleos objeto del presente estudio, ha demostrado ser efectiva en el tratamiento de las queilitis por contacto.</p
... People who experience Factitial Cheilitis are often found to have psychological disorders, excessive anxiety or psychosocial stress. Some of these factors can cause difficulty smiling, speaking, and discomfort while eating [5,6]. ...
... Early literature suggested a female predisposition for the condition, particularly when exfoliative and factitious cheilitis were used interchangeably and when exfoliative cheilitis was found to be associated with underlying psychiatric disorders (Crotty and Dicken, 1981;Daley and Gupta, 1995;Taniguchi and Kono, 1998;Thomas et al., 1983). A recent retrospective study found a 2:1 female-male ratio in exfoliative cheilitis cases diagnosed from 2000 to 2010 (Almazrooa et al., 2013). In any population, the condition is generally refractory to treatment. ...
Background: Exfoliative cheilitis is a condition of unknown etiology characterized by hyperkeratosis and scaling of vermilion epithelium with cyclic desquamation. It remains largely refractory to treatment, including corticosteroid therapy, antibiotics, antifungals, and immunosuppressants.
Objective: We sought to evaluate the safety and efficacy of excimer laser therapy and narrowband ultraviolet B therapy in female patients with refractory exfoliative cheilitis.
Methods: We reviewed the medical records of two female patients who had been treated unsuccessfully for exfoliative cheilitis. We implemented excimer laser therapy, followed by hand-held narrowband UVB treatments for maintenance therapy, and followed them for clinical improvement and adverse effects.
Results: Both patients experienced significant clinical improvement with minimal adverse effects with excimer laser therapy 600-700 mJ/cm2 twice weekly for several months. The most common adverse effects were bleeding and burning, which occurred at higher doses. The hand-held narrowband UVB unit was also an effective maintenance tool.
Limitations: Limitations include small sample size and lack of standardization of starting dose and dose increments.
Conclusion: Excimer laser therapy is a well-tolerated and effective treatment for refractory exfoliative cheilitis with twice weekly laser treatments of up to 700 mJ/cm2. Transitioning to the hand-held narrowband UVB device was also an effective maintenance strategy.
Cheilitis, or inflammation of the lips, is a common reason for dermatologic consultation. The inflammation can include the vermillion lip, vermillion border, and surrounding skin, and can present with an acute or chronic course. There are many etiologies, including irritant and allergic contact dermatitis, atopic cheilitis, actinic cheilitis, infectious etiologies, nutritional deficiencies, drug-induced cheilitis, and rare etiologies, including granulomatous cheilitis, cheilitis glandularis, plasma cell cheilitis, lupus cheilitis, and exfoliative cheilitis. Distinguishing among the various etiologies of cheilitis is clinically difficult, as many causes may produce similar erythema and superficial desquamation of mucosal skin. In addition, patients report dryness, redness, irritation, burning, fissuring, and itch in many of the underlying causes. Thus, the specific etiology of cheilitis is often difficult to diagnose, requiring extensive testing and treatment trials. In this review, we summarize the various types of cheilitis, synthesizing novel cases, clinical presentations, histopathology, epidemiology, and advancements in diagnostic methods and therapeutics. We provide a diagnostic algorithm aimed to assist clinicians in the management of cheilitis.
Cheilitis is a generic term that denotes inflammation of the lips. However, specific types of cheilitis have been described that may represent a variety of systemic and local disorders. Accurate diagnosis is key in identifying the pathology and administering of the proper treatment. Types of cheilitis described include angular cheilitis, exfoliative cheilitis, allergic contact cheilitis, actinic cheilitis, cheilitis glandularis, and cheilitis granulomatosa. Diagnosis is most often clinical, with biopsy needed in actinic cheilitis, cheilitis, glandularis, and cheilitis granulomatosa. Topical or systemic treatment may be indicated according to diagnosis. Moisturizing agents are frequently needed to enable better treatment.
This case report describes the first known successful treatment of exfoliative cheilitis with the interleukin-4 receptor alpha antagonist dupilumab in an adult patient. With no response to topical tacrolimus, hydrocortisone, dapsone, crisaborole or systemic doxycycline, low dose isotretinoin, or methotrexate, she had resolution with off-label dupilumab after 4 months of treatment.
Cheilitis is a term given to the inflammation that occurs in the vermillion of the lips. The exfoliative type is an uncommon form of cheilitis, which is characterized by inflammation and desquamation of the lip. It can cause aesthetic problems and compromise daily eating and phonation. The aim of this paper is to describe two cases of exfoliative cheilitis in young persons under periods of emotional stress and parafunctional habits. A 22-year-old white male and an 18-year-old black female presenting edema, intense dryness, and slight desquamation on the vermilion of the lips. In the second case, fissures with bleeding were also observed. Oral lesions were associated with intense emotional stress. The diagnosis of both was made based on the clinical presentation and the exclusion of other conditions. Although the patients have presented a significant improvement after the corticosteroid treatment, they still have a recurrence in stressful episodes. Detailed clinical examination and complementary exams are fundamental for determining associated factors and correctly diagnosing exfoliative cheilitis. Treatment can be challenging, especially in the face of relapses.
Key words:Cheilitis, exfoliative cheilitis, oral lesions, stress psychological.
Exfoliative cheilitis is a hardly diagnosed disease by pediatricians. We have presented this report to draw the attention of clinicians
because the child is the youngest patient with complete relief from using tacrolimus ointment in the literature. We present the three-year-old child with scaled, crusted, and sensitive upper and lower lips. He was admitted to different centers from the beginning
of the complaints without any relief despite different treatments. The clinicians may encounter exfoliative cheilitis in different age
groups. There are some approaches to management and therapy of the disease. But consensus has not yet occurred on definitive
treatment, especially in childhood.
Objective
Since the aetiologies of cheilitis are broad and overlapping, the purpose of this cross-sectional clinical study was to examine the multiple factors involved in aetiology and the disease's clinical features.
Subjects and Methods
We analysed cheilitis prevalence, demography, clinical features, patients` habits, psychological stress, systemic diseases, vitamin B9, B12 and iron serum levels and allergy test results in a total of 130 subjects with cheilitis, plus 22 healthy subjects.
Results
The most common cheilitis types were: cheilitis simplex and eczematous cheilitis (28.5%); herpetic cheilitis (16.9%); and exfoliative and angular cheilitis (7.7%). Concerning bad habits, there was a significant association/connection between self-reported saliva at the corners of the mouth and angular cheilitis, and between lip licking/biting and exfoliative cheilitis. Common associated conditions were skin diseases (56.5%) and atopy (84%). Vitamin B9 and B12 serum and iron values were mostly within the normal reference range. The patients suffering from herpetic cheilitis had significantly higher psychological/mental stress levels than the control group.
Conclusion
To our knowledge, this is the first study of cheilitis patients that has simultaneously analysed etiological factors, characteristics of the disease, and diagnostic parameters.
Background/purpose
Exfoliative cheilitis (EC) is a chronic and reversible inflammatory disease of the lips without definite etiology. Clinically, different types of allergens can be found in exfoliative cheilitis patients, however, few studies have focused on the relationship between exfoliative cheilitis and hypersensitivity. This research aimed to investigate the prevalence of hypersensitivity in EC patients.
Materials and methods
A prospective study was conducted in 30 patients with exfoliative cheilitis and 30 healthy controls, matched in age and sex. Laboratory tests included serum total IgE, allergen-specific IgE, and food-specific IgG.
Results
Increased serum total IgE level, positive food-specific IgG were seen more frequently in exfoliative cheilitis patients than in healthy control (P < 0.05). Special IgE level to FX5 and the degree of food-specific IgG to wheat were seen higher in exfoliative cheilitis patients than in healthy control (P < 0.05).
Conclusion
This study suggests that patients with exfoliative cheilitis may have predisposition of hypersensitivity. The detection of allergens should be strengthened in the future clinical work.
Tacrolimus (TAC, FK506) is a major calcineurin inhibitor and has been commonly used in treatments of patients with organ transplants and immune diseases. Moreover, tacrolimus is recommended by the treatment guidelines for oral potentially malignant disorders (OPMDs) such as oral lichen planus (OLP). However, whether tacrolimus increases the risk of cancer remains controversial. We observed that in a 4-Nitroquinoline N-oxide (4NQO)-induced oral carcinogenesis model, tacrolimus treatment was associated with a significantly lower ratio of cancer formation (52.94% vs. 90%) and a lower proportion of Ki67 and proliferation cell nuclear antigen (PCNA) -positive cells in lesion areas (P < 0.001). Liver, kidney, and lung functions of rats and the tumor immune microenvironment of the tongue were not affected. These observations suggest that tacrolimus blocked oral carcinogenesis through epithelial cell proliferation inhibition, independent of its immunosuppressive effects. As a processing factor, tacrolimus decreased tumor formation and cell proliferation in different stages of oral squamous cell carcinoma (OSCC) progression in vivo and in vitro. Furthermore, we investigated effects on the cell cycle and expression of related proteins. Tacrolimus induced G1/S phase arrest and significantly downregulated the expression of cyclinD1, cyclinE1, and c-Myc. These results suggest that tacrolimus induces G1/S phase arrest via inhibition of cyclinD1, cyclinE1, and c-Myc expression and retards oral cell carcinogenesis in vitro and in vivo. Thus, application of tacrolimus is a safe therapeutic strategy for treating OPMDs.
Objective
To present a brief review of the literature on the different types of cheilitis, focusing on the clinical, histopathological and treatment characteristics.
Methods
Electronic databases were searched for studies assessing published researches and case reports on all types of cheilitis.
Results
Cheilitis is the term that refers to the inflammatory state of the lips, which may involve the perioral region, lip vermilion and/or labial mucosa, with lip vermilion being the most affected area. There are different types of cheilitis and amongst the most commonly reported in the literature there are: actinic, desquamative/factitious, glandular, contact/eczematous, angular, granulomatous, plasma cell, associated or secondary to skin or systemic diseases, drug-induced or drug reaction cheilitis.
Conclusions
The diagnosis of inflammatory conditions of the lips requires a complete clinical examination and, when necessary, complementary tests in order to achieve a correct diagnosis and satisfactory treatment for the different conditions. Dental surgeons and physicians must know the importance of the correct diagnosis to indicate the best therapy for each type of cheilitis, aiming patients’ well-being and better prognosis.
Background
Tacrolimus has been used to treat various inflammatory skin diseases, but its safety for topical application on the oral mucosa is unknown. Exfoliative cheilitis (EC) is a chronic inflammatory disorder of the lips characterised by repeated scaling; it is difficult to manage. The aim of this study was to assess the efficacy and safety of tacrolimus 0.03% ointment as a topical treatment in patients with EC.
Methods
In this randomised controlled clinical trial, 40 patients with EC were randomly assigned to receive either tacrolimus 0.03% ointment (experimental group, n = 20) or triamcinolone acetonide 0.1% cream (control group, n = 20) treatment for a 3‐week period. Medication was administered in 3, 2, and 1 daily doses during the first, second, and third weeks, respectively. The patients with complete healing were followed up for 3 months. The clinical outcomes were measured, including the scores regarding signs (scale, dryness, rhagades, and swelling) and symptoms (rough, dry, pain, pruritus, and burning sensation) at every visit. Blood concentrations of tacrolimus were assessed.
Results
After the 3‐week treatment, healing rates of scale in the experimental and control groups were 65% and 10%, respectively (P = 0.018). Improvement in all signs and two symptoms (rough, pruritus) was much greater in the experimental group (P < 0.05). The 3‐month recurrence rate was higher in the control group (P = 0.029). Tacrolimus blood concentrations were in the safe range (< 5 ng/mL).
Conclusion
Topical tacrolimus 0.03% ointment has good short‐term efficacy and safety for treating EC.
Currently, there are no clear recommendations for diagnostic management of lip inflammation and cheilitis, which is evident in the varied nomenclature and subtypes found in medical literature on cheilitis. This can confound diagnostic management. We therefore recently put forth a proposal for cheilitis classification, defining three groups of cheilitis based on duration and etiology: mainly reversible cheilitis, mainly irreversible cheilitis, and cheilitis connected to other diseases. The most common forms of cheilitis are the reversible types, usually of short duration and commonly easily resolved or treated. In contrast, irreversible types of cheilitis are rare, are harder to treat, and are confirmed only after a biopsy of an inflamed lesion. To correctly diagnose and manage the different types, practitioners must consider several factors, including visible manifestations of the disease, related diseases and symptoms, personal habits, weather conditions, allergies, nutritional deficiencies, and results from tissue swabs and biopsies. In addition, multispecialty collaboration and communication involving dermatology, oral pathology, clinical immunology, otorhinolaryngology, rheumatology, and other fields can be crucial for patient outcome. We believe our classification system would be of great benefit to researchers, patients, and doctors by simplifying both nomenclature and disease recognition, thus ensuring timely and adequate treatment.
Background: Tacrolimus is a new type immunosuppressant. The aim of this study was to evaluate the effectiveness of topical tacrolimus 0.1% ointment at 2 different frequencies in treating patients with exfoliative cheilitis.
Methods: A total of 40 patients with exfoliative cheilitis were randomly divided into QD group receiving topical tacrolimus 0.1% ointment once a day or QOD group receiving topical tacrolimus 0.1% ointment once-two-day. Patients were also applied wet dressing of saline twice a day. The effectiveness of treatment was defined as the percentage of improvement in signs or symptoms.
Results: 37 patients completed the 2-week treatment. And, a full set was analyzed. The effectiveness of topical tacrolimus 0.1% ointment for relief in objective sign and subjective symptom was 50% and 67.5%% in QD group, respectively. For QOD group, the effectiveness of sign and symptom relief was 50% and 73.5%. There was no significant difference of effectiveness between application topical tacrolimus once a day and once two days.
Conclusion: Our data suggested that application of topical tacrolimus 0.1% ointment once a day and once two days had similar clinical effectiveness for sign and symptom relief in patients with exfoliative cheilitis.
Background:
The aim of the present study was to describe and compare the oral and dental health status of two groups, one diagnosed with eating disorders (EDs), and another group without this pathology, assessing the following oral manifestations: dental alterations, periodontal disorders, soft tissue disorders, non-stimulated salivary flow, and oral pH.
Material and methods:
This comparative transversal epidemiological study included 179 participants, of whom 59 were diagnosed with EDs (Eating Disorder Group: EDG) and 120 had no antecedents of EDs (No Eating Disorder Group: NEDG). All patients fulfilled the following inclusion criteria: women aged over 18 years, diagnosed with an ED by a specialist, patients who had undergone at least 1 year monitoring by the Clinical Nutrition Unit, and had not received any periodontal treatment during the previous 6 months. Both groups were homogeneous in terms of sex, age, education, and socioeconomic level. Oral exploration was performed, registering clinical variables, as well as sociodemographic and socioeconomic data, oral hygiene habits, and smoking. Statistical significance was established as p<0.05 (confidence level > 95%).
Results:
The dental erosion (DE) was the most significative feature of dental alterations. The degree of DE was significantly greater in the EDG (p<0.001). A significant association between soft tissue lesions and EDs was found (p<0.001) A notable difference in non-stimulated salivary flow was found between the groups (p<0.001). No significant differences between the groups were found for periodontal status, dental caries, or oral hygiene practices.
Conclusions:
On the basis of the results obtained, it is necessary to carry out oral/dental examination as soon as an ED is diagnosed with regular check-ups thereafter.
Background:
The terms exfoliative cheilitis, factitial cheilitis, and morsicatio labiorum are used to describe self-inflicted lesions of the lip.
Objective:
Here we report and analyze clinical, pathological, and therapeutic data on 13 patients with a form of factitial cheilitis that we believe should be considered a separate entity.
Results:
Eight patients were male and 5 patients were female. All patients reported pain and presented with crusts consisting of dried saliva and topical medications adherent to the surface of the lips. These patients expressed great concern with their condition, and reported several previous, ineffective treatments. Simple reassurance only was not effective; saline compresses alleviated symptoms for a few patients. Most patients were lost to follow-up. Biopsies were not performed on all patients.
Conclusion:
This particular type of cheilitis artefacta has been previously described, but some features described herein are new and allow a specific approach: patient's behavior, the "protrusion sign," and possible improvement with antidepressants. For these cases, we propose the term ointment pseudo-cheilitis because it comprises the nature of the attached material and the lack of true inflammation. Further psychiatric characterization is a logical next step in further characterizing this difficult-to-treat condition.
Liplikeczeem (lip-licking dermatitis) is een contacteczeem dat ontstaat door het frequent likken van de lippen en de omliggende huid. Door het herhaaldelijk contact met speeksel wordt de huid beschadigd en raakt vervolgens ontstoken.
Objective:
To systematically review treatments of exfoliative cheilitis based on symptom patterns in
terms of Traditional Chinese Medicine.
Methods:
PubMed, Cochrane Central Register of Controlled Trials and Wanfang data were screened
for case reports, case series or clinical trials that were published in English or Chinese from January,
1973 to September, 2015. The keyword of "exfoliative cheilitis or scaling cheilitis or factitious cheilitis"
was used. Effectiveness or ineffectiveness was investigated as outcome for Meta analysis, which is
based on effective index in each study. Response to treatment was described for case reports or case
series.
Results:
From 38 screened studies, 17 were randomized controlled trials (RCTs), 5 were single-arm
trials, and 16 were case reports or case series. Three RCTs were eligible for Meta analysis and all of them
compared managements between Traditional Chinese Medicine and corticosteroids for exfoliative
cheilitis, which involved 223 participants. Interestingly, data of Meta analysis showed similar effect of
Traditional Chinese Medicine and corticosteroids for patients with exfoliative cheilitis [relative risk ratio:
1.10; 95% CI (1.00-1.21), P = 0.06].
Conclusion:
Traditional Chinese Medicine might be a substitute for corticosteroids on exfoliative
cheilitis. However, the evidence and recommendation of exfoliative cheilitis managements need to
be taken with caution because of the low quality of evidence in the studies obtained.
Objective
To identify patients evaluated in an outpatient setting at our institution with a presentation of recurrent orofacial swelling and to review the spectrum of causes to outline a diagnostic approach.
Patients and Methods
A retrospective study of 104 patients with more than 1 episode of orofacial swelling lasting for more than 5 days identified through a keyword search of the electronic health record from January 2, 2000, through July 5, 2011.
Results
Patients were categorized according to final cause of orofacial swelling: idiopathic orofacial granulomatosis, solid facial edema due to rosacea and acne vulgaris, Crohn disease, contact dermatitis, sarcoidosis, exfoliative cheilitis, lichen planus, actinic cheilitis, cheilitis glandularis, lymphedema, miscellaneous, and multifactorial. Granulomatous inflammation was noted on biopsy in 40 of 85 patients (47%). Oral involvement was associated with Crohn disease (P<.001), and facial and periorbital swelling was associated with solid facial edema in the setting of rosacea and acne vulgaris (P<.001).
Conclusion
The broad range of diagnoses responsible for recurrent orofacial swelling underscores the diagnostic challenge and importance of a thorough multidisciplinary evaluation to identify underlying causes.
This series of three papers reviews the causes, diagnosis and differential diagnosis, and outlines the management of sore and/or swollen lips.
CPD/Clinical Relevance: Sore and/or swollen lips are not uncommon, often have a local cause but may reflect a systemic disease. The previous 2 papers in the series discussed their causes. This paper reviews their diagnosis and treatment.
This series of three papers reviews the causes, diagnosis and differential diagnosis, and outlines the management of sore and/or swollen lips.
CPD/Clinical Relevance: Sore and/or swollen lips are not uncommon, often have a local cause, but may reflect a systemic disease. The previous article reviewed important causes, from actinic to contact cheilitis, while this paper starts with drug-induced cheilitis and completes that alphabetical list.
The oral mucosa is normally semitranslucent, allowing the color of underlying tissues to show through to a variable degree. Lesions may appear white secondary to increased thickness of the epithelium or decreased subepithelial vascularity, however, the etiology of white lesions is quite varied. This chapter reviews commonly seen benign white lesions of the oral cavity, with attention to differential diagnosis and treatment recommendations.
This paper reports on the case of a 19-year-old female who presented to the Oral Medicine clinic with a chief complaint of scaly and peeling lips. The lesions had persisted on her lips for more than 7 years and were refractory to previous treatment. Her physician’s diagnosis was contact dermatitis. We diagnosed this patient as having exfoliative cheilitis (EC). A patch test using toothpaste containing sodium lauryl sulfate (SLS) was positive and the patient changed her toothpaste to one without SLS. One year after treating her lesions with hydrogen peroxide mouthwash 1% and glycerin borax, the lesions showed gradual improvement until returning to normal. Glycerin borax was safe, low cost, and simple to use in the treatment of refractory EC. SLS may have been a precipitating factor in EC in this case.
Key words: cheilitis, exfoliative, glycerin borax, hydrogen peroxide, sodium lauryl sulfate
Cheilitis is a generic term that denotes inflammation of the lips. However, specific types of cheilitis have been described that may represent a variety of systemic and local disorders. Accurate diagnosis is key in identifying the pathology and administering of the proper treatment. Types of cheilitis described include angular cheilitis, exfoliative cheilitis, allergic contact cheilitis, actinic cheilitis, cheilitis glandularis, and cheilitis granulomatosa. Diagnosis is most often clinical, with biopsy needed in actinic cheilitis, cheilitis, glandularis, and cheilitis granulomatosa. Topical or systemic treatment may be indicated according to diagnosis. Moisturizing agents are frequently needed to enable better treatment.
Authors describe a case of recurrent exfoliative cheilitis that responded to treatment with a standardized topical preparation of Calendula officinalis L. An eighteen-year-old man was referred to UNESP - São Paulo State University, Department of Biosciences and Oral Diagnosis, São José dos Campos Dental School to investigate a chronic dry scaling lesion on his lips. The patient's main chief was aesthetic compromising. Corticoid therapy was suspended and Calendula officinalis ointment 10% for ad libitum use has been prescribed. The results presented allow the authors to consider Calendula officinalis L. as a potential therapy in cases of cheilitis exfoliative.
Exfoliative cheilitis, one of a spectrum of diseases that affect the vermilion border of the lips, is uncommon and has no known cause. However, factors such as stress and some psychiatric conditions are associated with the onset of the disease. This condition is disabling because esthetics and normal functions such as eating, speaking and smiling are compromised. The lack of specific treatment makes exfoliative cheilitis a chronic disease that radically affects a person"s life. This report attempts to further investigate the clinical course of the disease and provides detailed illustrations of the cyclical nature of the disease.
Factitious cheilitis is a chronic condition characterized by crusting and ulceration that is probably secondary to chewing and sucking of the lips. Atopy, actinic damage, exfoliative cheilitis, cheilitis granulomatosa or glandularis, contact dermatitis, photosensitivity reactions and neoplasia should be considered in the differential diagnosis of crusted and ulcerated lesions of the lip.
We present a 56 year-old female with an ulcerated and crusted lesion on her lower lip. The biopsy showed granulation tissue and associated inflammation but no malignancy. Based on the tissue examination and through clinical evaluation the diagnosis of factitious cheilitis was rendered.
Thorough clinical history, utilization of basic laboratory tests and histopathologic evaluation are required to exclude other diseases and a thoruough psychiatric evaluation and treatment is vital for successful management of these patients.
Background: Cheilitis is a common problem, the cause of which is often obscure.
Objective: Data on 75 cases of recalcitrant cheilitis were analyzed. These had been referred to a tertiary care center.
Methods: Each of the 75 patients had undergone a detailed history, physical examination, and patch tests.
Results: Of the patients, 53 were female (67%), and the age range was 9 to 79 years. Of the cases, 36% included irritant contact dermatitis (ICD), 25% included allergic contact dermatitis (ACD), 19% were attributed to atopic eczema, and in 9% the dermatitis was of unknown cause. Nine percent were noneczematous. The materials causing ACD were medicaments applied to the lips, lipstick ingredients, sunscreen agents, toothpaste ingredients, colophony in dental floss and toothpicks, nail varnish, cosmetics, and nickel in the mouthpiece of a flute.
Conclusion: The most common cause of cheilitis was irritation, frequently caused by liplicking. About one quarter was caused by ACD. Medicaments, lipsticks, sunscreens, and toothpaste were the most common allergens. Atopic eczema is a commonly overlooked cause of cheilitis. However, there is a troublesome group of patients, 9% in this series, who are often severely affected, but the cause of their cheilitis remains obscure.
Exfoliative cheilitis is an uncommon condition affecting the vermilion zone of the upper, lower or both lips. It is characterized by the continuous production and desquamation of unsightly, thick scales of keratin; when removed, these leave a normal appearing lip beneath. The etiology is unknown, although some cases may be factitious. Attempts at treatment by a wide variety of agents and techniques have been unsuccessful. Three patients with this disease are reported and its relationship to factitious cheilitis and candidal cheilitis is discussed.
Morsicatio mucosae oris (MMO) presents as white papules and plaques that may resemble leukoplakia, and are often biopsied. The objective of this study is to document the clinical features and histopathology of MMO and to reevaluate the prevalence of dysplasia and/or cancer when this frictional keratosis is removed from the category of leukoplakia.
Cases that were submitted to a single laboratory with a provisional diagnosis of "leukoplakia," "hyperkeratosis," or "white lesion" were evaluated.
Fifty-six lesions of MMO from 56 patients were identified out of 584 white lesions. Most cases occurred in the third to sixth decades of life. Thirty (53.6%) and 18 (32.1%) out of 56 lesions were located on the lateral tongue and buccal mucosa, respectively. The lesions showed hyperparakeratosis with a characteristic frayed, shaggy, peeling surface, and acanthosis with insignificant inflammation. When MMO is removed from the category of leukoplakia, the percentage of true leukoplakia that are dysplastic or malignant increased by 12.9%.
MMO is a form of chronic oral frictional keratosis that has no malignant potential, and should be signed out as such and not merely "hyperparakeratosis and acanthosis" so that it can be removed from the category of leukoplakia where it does not belong.
Chronic eczematous cheilitis comprises a heterogeneous group of disorders, the cause of which often remains obscure. Our object was to investigate the frequency of contact allergy in a cohort of patients with chronic eczematous cheilitis attending a tertiary referral clinic. Patients (106 females and 23 males) with chronic eczematous cheilitis were analyzed retrospectively. All patients were tested with a standard patch test series and a fraction with a dedicated patch test series. Children were also tested with atopy patch tests. Moreover, all patients were investigated for past or current presence of atopic diseases. Patch-test reactions of possible or probable relevance were detected in 84 patients (65.1%; 72 females; median age 40), of uncertain or not relevant significance in 26 (20.1%) and negative in 19 (14.7%). An extended series was necessary to reveal hapten hypersensitivity in 42 patients. The most frequent causes of allergic cheilitis were nickel, fragrances, balsam of Peru, chromium salts and manganese salts, present primarily in cosmetics, dental materials and oral hygiene products. Twenty four patients (18 females; median age 21; 18.6%) were diagnosed as having atopic dermatitis of the lips. Four children had allergic contact cheilitis to haptens or food allergens, whereas six had atopic cheilitis. Twenty one cases (16.3%) were considered irritant contact cheilitis. Allergic contact cheilitis is common in adult patients, with the haptens responsible varying with age. Patients with chronic eczematous cheilitis should undergo extended patch testing.
Exfoliative cheilitis is an uncommon lip lesion usually of great concern to the patient and quite refractory to treatment. The available literature was surveyed, and 3 cases have been described to illustrate various aspects of the condition. The difficulty of treating such lesions has been discussed, and a proposition put forward that the lesions are of a factitious nature.
Four cases of factitious crusting of the lips in women are reported. Two of the women had hemorrhagic crusts, and two had keratotic yellow crusts. All four patients had personality disturbances. Biting, picking, or unconscious licking of the lips may be the underlying mechanism for trauma and crust formation. This entity should be distinguished from contact cheilitis, actinic cheilitis, infectious cheilitis glandularis, and cheilitis granulomatosa. Some cases of exfoliative cheilitis may also be factitious. The presence of bizarre hemorrhagic or keratotic crusts on the lips should alert the clinician to a possible factitious origin, and a psychiatric evaluation should be done.
Exfoliative cheilitis is an uncommon condition affecting the vermilion zone of the upper, lower or both lips. It is characterized by the continuous production and desquamation of unsightly, thick scales of keratin; when removed, these leave a normal appearing lip beneath. The etiology is unknown, although some cases may be factitious. Attempts at treatment by a wide variety of agents and techniques have been unsuccessful. Three patients with this disease are reported and its relationship to factitious cheilitis and candidal cheilitis is discussed.
We examined a 16-year-old male with persistent crusting of the lips. Biopsy showed parakeratosis, which is a normal feature, and a mild inflammatory infiltrate without fungal infection. These findings are compatible with a diagnosis of exfoliative cheilitis. Medication with anti-depressants was helpful. To date, the condition has been reported under various names: factitious cheilitis, localized crusting as an artifact, factitious lip crusting, and exfoliative cheilitis, because some cases are thought to be factitious. We suggest to call this condition 'factitious type' or 'idiopathic type' of exfoliative cheilitis, respectively, independent of the presence of a psychiatric problem.
Cheilitis is a common problem, the cause of which is often obscure.
Data on 75 cases of recalcitrant cheilitis were analyzed. These had been referred to a tertiary care center.
Each of the 75 patients had undergone a detailed history, physical examination, and patch tests.
Of the patients, 53 were female (67%), and the age range was 9 to 79 years. Of the cases, 36% included irritant contact dermatitis (ICD), 25% included allergic contact dermatitis (ACD), 19% were attributed to atopic eczema, and in 9% the dermatitis was of unknown cause. Nine percent were noneczematous. The materials causing ACD were medicaments applied to the lips, lipstick ingredients, sunscreen agents, toothpaste ingredients, colophony in dental floss and toothpicks, nail varnish, cosmetics, and nickel in the mouthpiece of a flute.
The most common cause of cheilitis was irritation, frequently caused by liplicking. About one quarter was caused by ACD. Medicaments, lipsticks, sunscreens, and toothpaste were the most common allergens. Atopic eczema is a commonly overlooked cause of cheilitis. However, there is a troublesome group of patients, 9% in this series, who are often severely affected, but the cause of their cheilitis remains obscure.
Exfoliative cheilitis is an unsightly and uncommon, chronic superficial inflammatory disorder that affects the vermilion zone of the lips. This case report describes the presentation of exfoliative cheilitis in a young man, and his subsequent management with antidepressant medication. The differential diagnosis of chronic exfoliative cheilitis is outlined.
Physical and chemical injuries. In: Oral and Maxillofacial Pathology
- Neville Bw Damm
- Allen Cm Dd
- Bouquot
- Je
Neville BW, Damm DD, Allen CM, Bouquot JE. Physical and chemical injuries. In: Oral and Maxillofacial Pathology. 3rd ed. St Louis, MO: Saunders; 2009:304-305.
BDS Division of Oral Medicine and Dentistry Brigham and Women's Hospital 75 Francis Street Boston, MA 02115 soulafa_almazrooa@hsdm
- A Soulafa
- Almazrooa
Soulafa A. Almazrooa, BDS
Division of Oral Medicine and Dentistry
Brigham and Women's Hospital
75 Francis Street
Boston, MA 02115
soulafa_almazrooa@hsdm.harvard.edu