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.
The mechanism depends on the cause of 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 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.
There are numerous clinical manifestations of traumatic cheilitis depending on the origin.
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 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.
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.
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.
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.
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.
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.
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.
The therapeutic management of cheilitis is symptomatic and etiological:
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. (Level V)
We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.
This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.
Click Your Answer Below
Would you like to access teaching points and more information on this topic?
|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]|
The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Dermatology. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.
StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Dermatology, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Dermatology, you will already be prepared.
Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Dermatology. When it is time for the Dermatology board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Dermatology.