Cheilitis


Article Author:
Amani Gharbi


Article Editor:
Wissem Hafsi


Editors In Chief:
Timothy Craig
Yoon Kim
Robert Hostoffer


Managing Editors:
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Scott Dulebohn
Sobhan Daneshfar
William Gossman
Pritesh Sheth
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Richard Ciresi
Hajira Basit
Phillip Hynes


Updated:
1/27/2019 8:36:35 AM

Introduction

Cheilitis is an inflammation of the lips. It may be acute or chronic, touch the skin part and/or the vermilion of both lips. It is a frequent reason for consultation and a consequence of several etiological factors, and it includes different clinical, histological and prognostic aspects.[1][2][3]

Etiology

The etiologies of cheilitis are numerous and varied. Each gives a rather special clinical aspect. They also determine the prognosis and management. They will be detailed below.

Pathophysiology

The mechanism depends on the cause of cheilitis.

History and Physical

Weather-Induced Cheilitis

The cold and wind are two factors that frequently cause drying and desquamation of the lips, which is followed by cracking. Transverse fissures appear secondarily that can become chronic, especially in the midline of the lower lip. Persistent lip-licking often aggravates these lesions, and sometimes by a bacterial or fungal secondary infection.

Chronic Actinic Cheilitis

Chronic actinic cheilitis is secondary to prolonged exposure, for years, to ultraviolet (UV) rays, often related to the professional context (agriculture, marine, outdoor work, altitude). More often it affects men in their 50s with clear skin. It predominately affects the lower lip. It can be desquamative, atrophic, sometimes leucokeratotic, even crustal, fissured, or erosive. The lesions can be unifocal, multifocal, or reach the entire vermilion. The limits between the vermilion and the skin are not clear. The photo-exposed skin may also be the site of actinic elastosis or actinic keratoses. Chronic actinic cheilitis has been classified by the World Health Organizations (WHO) as a "potentially malignant condition." UV light causes damage to DNA, causing mild to moderate dysplasia, which can progress to squamous cell carcinoma. One or more biopsies are recommended for dysplasia or carcinoma, even in the absence of clinical signs of malignancy. The carcinomatous transformation is systematically evoked in cases of induration, infiltration or ulceration of chronic actinic cheilitis, and needs to be investigated with multiple biopsies.

Acute Actinic Cheilitis

It is related to intense exposure to UV radiation. It primarily affects the lower lip, which is more exposed to ultraviolet (UV) than the upper lip. It is a painful condition with erythema and edema, and possibly even vesicles and bullae followed by erosions and crusting. Skin conditions involving increased photosensitivity (photosensitivity in lupus, drug-induced photosensitivity, in particular, due to voriconazole) are predisposing factors.

Differential diagnoses are herpetic recurrence disease, photodermatosis (lupus), photosensitization induced by topical or systemic drugs.

Allergic Cheilitis

Allergic cheilitis is secondary to contact with an allergenic substance related to a delayed hypersensitivity reaction. It can be acute or chronic. In acute cases, it produces erythema, edema, and vesicles, followed by crusting and pruritus. The lesions are poorly delineated, crossing over to the cutaneous side of the lips and sometimes further. Chronic allergic cheilitis is dry, erythematous and squamous, and there may even be fissures; there may be moderate pruritus or none at all. Allergens are multiple, that is why the diagnosis is difficult.

Anamnesis must be precise and detailed to look for any causative agent in contact with the oral mucosae; patch testing can confirm the diagnosis of delayed hypersensitivity in some cases.

Traumatic Cheilitis

There are numerous clinical manifestations of traumatic cheilitis depending on the origin.

  • Persistent lip-licking, common in children, causes chronic inflammation of the vermilion borders with clearly demarcated perioral erythema. Secondary candidal and bacterial infections are common.
  • Persistent lip-nibbling or an abnormal dental occlusion can be accompanied by cheilitis. 
  • Factitious cheilitis or exfoliative cheilitis, which is seen in adolescents and younger subjects, presents as a squamous and crusted maceration of the lips, which is sometimes very thick and unpleasant. This condition is considered to be a pathogenesis. It is provoked and maintained by chronic licking and rubbing of the lips. Appropriate psychological management is needed.

Caustic Cheilitis

Caustic cheilitis is an acute irritation of the lips, or even a burn, secondary to the topical application of a chemical product. Clinically, there is painful inflammatory edema which may progress to bullous or phlyctenular, then erosive and crusty lesions. Lesions are limited to the contact area. In severe cases, lesions may be necrotic and ulcerated depending on the product causing it.

Atopic Cheilitis

Atopic patient (adult or child) may have erythematous and squamous cheilitis with fissures of both lips and commissures associated with lichenification, or even radial peri-buccal fissures. Pruritus is common. It can occur alongside a flare-up of the skin disease or separately.

Immuno-Allergic Cheilitis

Erythema multiforme (EM) and Stevens-Johnson syndrome (SJS) are mucocutaneous and systemic manifestations side effects of an immuno-allergic reaction to an infectious agent (EM) or drug (SJS). Oral involvement is very evocative. It presents as erosive and crusty cheilitis associated with diffuse erosive stomatitis.

Drug-induced Cheilitis

Retinoid treatments (isotretinoin, acitretin, alitretinoin) may cause erythematous and squamous cheilitis that is dry and erosive with fissures. It correlates with a daily dose of treatment.

Infectious Cheilitis

Viral cheilitis: It is mainly due to the herpes simplex virus, especially type 1. The primary herpes infection (herpetic gingivostomatitis) combines post-vesicular erosive and crusted cheilitis with diffuse stomatitis leading to dysphagia, perioral vesicles, fever and cervical lymphadenopathy. Recurrence of oral herpes affects the lips in most cases. It manifests as a cluster of vesicles accompanied by a burning sensation. Next, the vesicles erode to leave behind crusted erosions that resolve in a week.

Bacterial Cheilitis: The most common cause of bacterial cheilitis is infection with group A Streptococcus or Staphylococcus

Mycotic cheilitis: Cheilitis caused by candida manifests with erythema and painful edema of the lips, sometimes with fissures, and it is usually accompanied by acute (pseudo-membranous candidiasis) or chronic stomatitis, and/or angular cheilitis. The diagnosis is confirmed by taking a specimen for mycological examination.

Parasitic cheilitis: Leishmaniasis is a possible cause of cheilitis in endemic regions. It gives the appearance of a chronic plaque ulcero-crustose, lipoid and painless, occupying part or the entire lip.

Cheilitis Glandularis

It is a chronic inflammation with tumefaction and sometimes suppuration of salivary glands at the lower lip and heterotopic salivary glands at the vermilion zone. The most cases are reported in adults between 50 and 70 years of age. The etiology is unknown, but it probably involves multifactorial causes associating irritation, mechanical, climate, and genetic factors. The most common clinical form is the simple cheilitis glandularis, which manifests as a moderate thickening of the lower lip with inflammatory dilated gland duct orifices, and pressure here will elicit a droplet of saliva.

Cheilitis Granulomatosa

This is labial edema affecting one or both lips that is intermittent at first, then permanent. The diagnosis is made following a biopsy that will demonstrate granulomas without necrosis, and with a lymphocytic infiltrate. Cheilitis granulomatosa can be isolated, idiopathic (Miescher cheilitis granulomatosa) or associated with various systemic conditions (sarcoidosis, Crohn’s disease, tuberculosis). The complete form of Melkersson Rosenthal syndrome combines cheilitis granulomatosa, peripheral facial paralysis, and a fissured tongue.

Nutritional Deficiency Cheilitis

Several nutritional deficiencies such as avitaminosis B2, B9, B12, scurvy (vitamin C), iron deficiency, or zinc deficiency may cause exfoliative cheilitis associated with other oral manifestations (stomatitis, erythematous glossitis). In pellagra (vitamin PP deficiency), vermilion is shiny and cracked, sometimes eroded. The diagnosis is made through biological assays.

Other Inflammatory Causes of Cheilitis

Lupus: All types of lupus can entail cheilitis.

Lichen: Keratotic lichen planus of the lips produces painless leukokeratosis. Erosive lichen planus triggers painful and widespread ulceration of the buccal mucosa and the lips.

Bullous Autoimmune: Pemphigus, in particular, can entail erosive and crusted cheilitis. Biopsy and immunofluorescence confirm the diagnosis. The cheilitis will resolve with treatment of the skin disease.

Evaluation

The diagnosis of most cheilitis is based on clinical signs and a careful anamnesis. A biopsy is required in cheilitis granulomatosa to confirm the diagnosis. Once the diagnosis of granulomatous cheilitis is made, a thorough etiological assessment is necessary. A biopsy is also important in chronic actinic cheilitis if there is suspicion of malignant transformation. Finally, in case of allergic cheilitis, an allergy survey is required. It includes a careful history and appropriate allergy tests.[4][5][6][7]

Treatment / Management

The therapeutic management of cheilitis is symptomatic and etiological:

  • The treatment for chronic actinic cheilitis aims to avoid progression to squamous cell carcinoma. Treatments include a vermilionectomy which is a surgical treatment, carbon dioxide-laser vaporization, electrocoagulation, cryotherapy (vaporization of the vermilion by application of liquid nitrogen), topical 5-fluorouracil (5-FU), imiquimod, and photodynamic therapy.
  • The treatment of acute actinic cheilitis is symptomatic (emollients, lip balm, sun protection in patients with a photosensitizing skin condition).
  • In allergic cheilitis, treatment consists of excluding the allergen responsible and applying a topical steroid.
  • In traumatic cheilitis, excluding the traumatic factor and applying a greasy topical protective agent is required. Psychotherapy may sometimes be needed for patients with a compulsive disorder.
  • In the case of caustic cheilitis, it is important to wash with water and to apply a topical steroid to reduce inflammation. Surgery is necessary in severe cases.
  • Greasy topical steroids applied twice a day for one week improve atopic cheilitis, and then it is prevented by using a hydrating topical agent and avoiding chronic licking the lips.
  • Drug-induced cheilitis requires routine treatment with an emollient.
  • Concerning the infectious cheilitis, treatment is based on antivirals, antibiotics, and antimycotics.
  • The treatment of inflammatory cheilitis during lupus, lichen or pemphigus is that of the disease.
  • In the nutritional deficiency cheilitis, the correction of the deficit allows the cure.
  • The treatment depends on the etiology of granulomatous cheilitis.

Enhancing Healthcare Team Outcomes

Because of the many causes of cheilitis, the management is best done with a multidisciplinary team. The key is to make the diagnosis and the cause. For patients with chronic actinic cheilitis, referral to a plastic surgeon, dermatologist and oncologist is recommended as the treatment may vary from surgery, topical chemotherapy, laser or photodynamic therapy. Acute cheilitis can be managed by the primary care provider or nurse practitioner by offering the patient emollients. Patients with allergic cheilitis may require topical steroids and infectious causes may require antibiotics. The prognosis for patients with cheilitis depends on the cause; however, recurrence is common. In chronic cases, the quality of life is poor. [8](Level V)

 

 


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Cheilitis - Questions

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Cheilitis - References

References

de Oliveira Bezerra HI,Gonzaga AKG,da Silveira ÉJD,de Oliveira PT,de Medeiros AMC, Fludroxycortide cream as an alternative therapy for actinic cheilitis. Clinical oral investigations. 2019 Jan 23;     [PubMed]
Nico MMS,Dwan AJ,Lourenço SV, Ointment Pseudo-Cheilitis: A Disease Distinct from Factitial Cheilitis. A Series of 13 Patients from São Paulo, Brazil. Journal of cutaneous medicine and surgery. 2019 Jan 17;     [PubMed]
Müller S, Non-infectious Granulomatous Lesions of the Orofacial Region. Head and neck pathology. 2019 Jan 9;     [PubMed]
Lugović-Mihić L,Pilipović K,Crnarić I,Šitum M,Duvančić T, Differential Diagnosis of Cheilitis - How to Classify Cheilitis? Acta clinica Croatica. 2018 Jun;     [PubMed]
Lopes MLDS,Gonzaga AKG,Mosconi C,Palomino GM,Mendonça EF,Batista AC,Silveira ÉJDD, Immune response and evasion mechanisms in lip carcinogenesis: An immunohistochemical study. Archives of oral biology. 2019 Feb;     [PubMed]
Evrard L, [Oral allergies]. Revue medicale de Bruxelles. 2018;     [PubMed]
Ayesh MH, Angular cheilitis induced by iron deficiency anemia. Cleveland Clinic journal of medicine. 2018 Aug;     [PubMed]
Samaranayake LP,Wilkieson CA,Lamey PJ,MacFarlane TW, Oral disease in the elderly in long-term hospital care. Oral diseases. 1995 Sep;     [PubMed]

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