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
Exfoliative (factitious) cheilitis
Plasma cell cheilitis
‘Chapping’ of the lips
• Reaction to adverse environmental
• 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
• Presenting as redness with
dryness, scaling and fissuring.
• Major causes- atopic
dermatitis and irritant or
allergic contact reactions
• Treatment- Emollients and
• A potent steroid may be
required to bring the
condition under control
• 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
• 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
• Persistent irritation and scaling or a more acute reaction
with oedema and vesiculation.
• Other forms of cheilitis vary greatly in their clinical
• 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 scalingexfoliative cheilitis must be excluded.
• If an allergic reaction is suspected, patch tests should be
• Treatment- Topical corticosteroids will give symptomatic
relief but the offending substance must be identified and
• Viral- HSV are common, and VZV and HPV may also affect
• 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
• 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
• 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
• Dry chapped lips
• Proliferation of bacteria (impetigo), yeasts (thrush) or virus
• 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
• Systemic illness, particularly IBD (ulcerative colitis
and Crohn disease)
• Sensitive skin, especially atopic dermatitis
• Genetic predisposition, for example in Down syndrome
• Oral retinoid
C/fPainful cracks / fissures
Blisters / erosions / ooze / crusting
It may progress to more widespread impetigo or candidal
skin infection on the adjacent skin and elsewhere.
Culture of swabs taken from the corners of the mouth may
TreatmentLip balm or thick emollient ointment, applied frequently
Topical or oral antibiotic
Topical antifungal cream
Oral antifungal medication
Topical steroid ointment
Filler injections or implants to build up the oral
• 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
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
• 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 paminobenzoic acid probably gives the best protection.
• Inflammatory changes and swelling of salivary glands in the
• 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
• 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
• In the most severe forms there
may be deep-seated infection
with abscess formation and
• 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
• 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
• 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
• 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
• 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.
• Mast cell stabilisers eg ketotifen
• Surgical reduction
• Presenting as continuous peeling of the lips.
• Factitial- if the behaviour triggering the condition is
• Exfoliative - obsessive-compulsive with no intent of gain.
• Mainly affects young adults <30 years with personality
• 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
• Other symptoms include sensations of: Tingling, Itch,
Dryness, Ulceration or fissuring may occur
Factitious cheilitis due to repeated lip sucking
• 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
• Genital areas are often
involved, k/a plasma cell
balanitis or vulvitis.
• Sometimes resistant to
• Recent reports show that
topical calcineurin inhibitors
• Involvement of the vermilion
zone is quite common in both DLE
• DLE can be premalignant, and
should be treated vigorously with
topical steroid ointments and
• Cheilitis of SLE more severe, with
erosions and haemorrhagic
• Lupus erythematosus can be very
difficult to distinguish from LP of
the lips, both clinically and by
• It is present from birth in some, which may indicate genetic
• There may be loss of sense of taste and decreased salivary
• 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 angiooedema 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
• In established cases, other causes of macrocheilia must be
• Lymphoma is a rare differential diagnosis.
• 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
• Treatment- Sunscreens, β-carotene, PUVA, and
• Oral thalidomide may be tried