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  1. 1. cheilitisM.N.KIRAN…GROUP:35
  2. 2. It’s a acquired lip lesion Synonym .Inflammation of the lip Cheilitis : Cheilitis may arise as a primary disorder of the vermilion zone or the inflammation may extend from nearby skin or, less often, from the oral mucosa
  3. 3. Chapping of the lips:Chapping is a reaction to adverse environmental conditionsusually caused by exposure to freezing cold or to hot dry winds.The keratin of the vermilion loses its plasticity, so that the lipsbecome sore, cracked and scaly. The affected person tends to lickthe lips, or to pick at the scales, which may aggravate thecondition.Treatment is by application of petroleum jelly and avoidance ofthe adverse environmental conditions
  4. 4. Eczematous cheilitisThe lips are often involved secondarily to atopic dermatitis The treatment is with emollients and topical corticosteroids.A potent steroid such as fludrocortisone may be requiredto bring the condition under control.
  5. 5. Contact cheilitis: Contact cheilitis is an inflammatory reaction provoked by the irritant or sensitizing action of chemicals. Many cases are caused by lipsticks or lipsalves but a large number of substances have been incriminated.
  6. 6. Drug-indused cheilitisHaemorrhagic crusting of the lips is a feature of erythema multiforme (particularly in Stevens– Johnson syndrom) but cheilitis can also occur as an isolated feature of a drug reaction.Aromatic retinoids such as etretinate and isotretinoin cause cheilitis, dryness and cracking of the lips in many patients .
  7. 7. Haemorrhagic crusting of the lipsin Stevens–Johnson syndrome
  8. 8. Infective cheilitisViral:Lip infections with HSV are common, and VZV and HPVmay also affect the lips. Rare viral infections such as orf 1-4 andvaccinia can affect the lips.
  9. 9. BACTERIAL: Dental infection or occasionally a furuncle or carbuncle may cause swelling of the lip. Impetigo may mimic herpes labiali Cancrum oris (fusospirochaetal infection) may cause labial and buccal necrosis.The lip is the most common 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
  10. 10. Protozoal:Cutaneous or mucocutaneous leishmaniasis typically causes swellings on the upper lip with later enlargement and destruction of the lip , refl ecting the three stages of oedema,granulomatous proliferation and then necrosis.Fungal:Blastomycosis and paracoccidioidomycosis are uncommoncauses of chronic ulceration affecting the lip, producing verysimilar clinical lesions to leishmaniasis .
  11. 11. Others:Red swollen lips with fi ssuring and exfoliation are prominent in mucocutaneous lymph node syndrome (Kawasaki disease).
  12. 12. ANGULAR CHEILITISAngular cheilitis is an acute or chronic infl ammation of the skin and contiguous labial mucous membrane at the angles of the mouth
  13. 13. Infective agents. These are the major cause. Candida or staphylococciAre isolated from most patients . Permanent cure can be achieved only by eliminating the Candida beneath the upper denture .Candidosis was probably responsible for some of the cases of cheilitis attributed to allergy to denture materials,since contamination of denture material by Candida may cause false-positive patch-test reactions.
  14. 14. Immune defi ciency: such as diabetes and HIV infection, may present with angular stomatitis .Outbreaks of acute pustular and fissured cheilitis may occur in children, particularly if they are malnourished, and in some cases streptococci or staphylococci have appeared to be causative .
  15. 15. Mechanical factors: In edentulous patients denture who do not wear a dentures, and also as a normal consequence of the ageing process, produce an oblique curved fold and keep the small area of skin constantly macerated.The recurrent trauma of dental flossing is a very rare cause of angular cheilitis.
  16. 16. Nutritional deficiencies, particularly defi ciencies of ribofl avin ,folate, iron and general protein malnutrition, may produce smooth,shiny, red lips associated with angular stomatitis, a combination called cheilosis . Crohn’s disease or orofacial granulomatosis . Clinical features. Angular cheilitis presents as a roughly triangulararea of erythema and oedema at one, or more commonly both,angles of the mouth . Linear furrows or fi ssures radiatingfrom the angle of the mouth (rhagades) are seen in the moresevere forms, especially in denture wearers
  17. 17. Diagnosis: This is usually obvious. Candida should be sought not only in the lesions but also beneath the denture. Treatment: Dentures should be removed from the mouth at night and stored in a candidacidal solution such as hypochlorite. Denture-related stomatitis should be treated with an antifungal. Miconazole may be preferable treatment for candidosis (creamapplied locally, together with the oral gel) As it has some Grampositivebacteriostatic action. New dentures that restore facial contour may help. The skin lesions should be swabbed and staphylococcalinfection treated with fusidic acid ointment or cream atleast four times daily.
  18. 18. Actinic cheilitis: • Actinic keratosis of lip • Solar cheilosisThis is a premalignant keratosis of the lip caused by exposure to solar irradations.Aetiology. Actinic cheilitis is most common in hot dry regions, in outdoor workers and in fair- skinned people (skin types I and II). The vermilion of the lower lip receives a high dose of UV irradiation because it is almost at right angles to the rays of the midday sun and is poorly protected by keratin and melanocytes. Most actinic cheilitis is seen on the lower lip of fair-skinned men in their fourth to eighth decade of life
  19. 19. Chronic actinic cheilitis withleukoplakia
  20. 20. pathologyHistology shows a fl attened or atrophic epithelium,beneath which is a band of infl ammatory infi ltrate in which plasma cells may predominate . Nuclear atypia and abnormal mitoses may be seen in the more severe cases, and some develop into invasive squamous carcinoma . The collagen generally showsbasophilic (elastotic) degeneration
  21. 21. Clinical fetures: Actinic cheilitis tends to affect the lower lip of adults who have had prolonged exposure to sunlight In the early stages there may be redness and oedema, but later the lips become dry and scaly. Later still, the epithelium becomes palpably thickened with small greyish-white plaques and, eventually, warty nodules may form. Eventually these may undergo malignant change, the possibility of which must alwaysbe considered when ulceration develops or when there are other suspect features such as:• A red and white, blotchy appearance with an indistinct vermilion border• Generalized atrophy with focal areas of whitish thickening• Persistent fl aking and crusting
  22. 22. Treament Treatment of actinic cheilitis is required to relieve symptoms and to prevent development of squamous carcinoma.• Topical agents: 5% fluorouracil three times daily for 10 days is suitable . Topical tretinoin , trichloracetic acid or diclofenac gel may also be effective. • Vermilionectomy (lip shave) . • Laser ablation . • Photodynamic therapy . Following treatment, prevention of recurrence by the regular use of a sunscreen lipsalve containing p-aminobenzoic acid probably gives the best protection [25,26]. Particular care should be taken to protect the vermilion of the lips with adequate sunscreens in patients with photosensitivity disorders such as xeroderma pigmentosum,and in those whose exposure to UVB is high, such asin farmers, fishermen, mountaineers, windsurfers and skiers
  23. 23. Actinic prurigof the lip
  24. 24. Actinic prurigo :is a type of familial photodermatitis, seen mainly in native Americans living at high altitudes especially inLatin America, and in China .It usually presents in young women as a photosensitive facial rash with pruritic lower lipcheilitis, and it may be associated with conjunctivitis, eyebrow alopecia and pterygion.Actinic prurigo is due to enhanced sensitivity to sunlight and is distinguished from actinic cheilitis, which is due to prolonged and excessive exposure to UV irradiation, by the relative absenceof epidermal dysplasia and solar elastosis .Polymorphic light eruption is almost invariably present in the actinic prurigo ofnative Americans .Treatment is with sunscreens, β-carotene, psoralen and UVA(PUVA), and antihistamines. Oral thalidomide may be tried
  25. 25. GlandularcheilitisGlandular cheilitis ischaracterized by inflammatory changes andswelling of salivaryglands in the lips
  26. 26. AetiOlOGYThis is an uncommon idiopat hic condit ion which in a f ew cases has appar ent ly been f amilial . Alt hough it was or iginally t hought t hat t he condit ion was due t o inf lammat ion of enlar ged het er ot opic salivar y glands, t he glands ar e of t en nor mal in size, dept h and hist ology [ 5]. I t is possible t hat t he excessive salivar y secr et ion f r om minor salivar y glands in t his condit ion might be an unusual clinical r esponse
  27. 27. PATHOLOGYIn the milder forms there is some fibrosis surrounding the salivary glands, while in the more severe forms there may be a dense chronic infl ammatory infiltrate. Only rarely do patients show genuine hyperplasia of the salivary glands or duct ectasia.
  28. 28. Clinical f eat ur esThe onset is at any age f r om childhood onwar ds.I n simple glandular cheilit is, t he lower lip is slight ly t hickened and bear s numer ous pinhead-sized or if i ces, f r om which mucous saliva can r eadily be squeezed. The upper lip is r ar ely involved.I n t he mor e sever e suppur at ive f or m (Vkmann’sch itis) th l is ol eil e ip consider ably and per manent ly enlar ged, and subj ect t o episodes of pain, t ender ness and incr eased enlar gement .The sur f ace is cover ed by cr ust s and scales, beneat h which t he salivar y duct or if ices may be discover ed. I n t he most sever e f or ms t her e may be deep-seat ed
  29. 29. treAtmentActinic cheilitis, if identified, should be treated appropriately.If the lips are grossly enlarged, excision of an elongated ellipse of tissue may be required; in other cases shave vermilionectomy may be all that is necessary.Other conditions such as atopic disease or factitial cheilitis would require different treatments
  30. 30. Granulomatouscheilitis:This is a chronic swelling of the lip dueto granulomatous infl ammationof unknown cause. Melkersson in 1928 described labialoedema in association with recurrentfacial palsy.Rosenthal in 1930 emphasized the roleof genetic factors and added scrotaltongue to the syndrome.The full syndrome has since beencalled Melkersson–RosenthalsyndromeIn Miescher’s cheilitis thegranulomatous changes are confi nedto the lip, and this is generally regardedas a mono symptomaticform of Melkersson–Rosenthalsyndrome, although the possibilityremains that these may be twoseparate diseases
  31. 31. AetiOlOGY The cause is unknown, but there may be a genetic predisposition to Melkersson–Rosenthal syndrome siblings have been affected and a scrotal tongue may be present in otherwise normal relatives. There is no convincing evidence that granulomatous cheilitis is due to an infective agent. Some cases may represent a localized form of sarcoidosis [6,7] or ectopic Crohn’s disease or orofacial granulomatosis. There is increasing evidence that some patients with granulomatous cheilitis are predisposed to Crohn’s disease In some cases, granulomatous cheilitis is followed some years later by regional ileitis A few patients react to cobalt or to food additives such as cinnamic aldehyde and have no extra oral lesions, although these reactions are by no means always relevant; for example, in one study only one of nine patients had a relationship between cheilitis and food intake
  32. 32. PAthOlOGYBiopsy of the swollen lip or facial tissues during the early stages of the disease shows only oedema and perivascular lymphocytic infiltration. In some cases of long duration no other changes are seen, but in others the infiltrate becomes more dense and pleomorphic and small focal granulomas are formed, indistinguishable from sarcoidosis or Crohn’s disease. Similar changes may be present in cervical lymph nodes . In some cases,small granulomas occur in the lymphatic walls
  33. 33. clinicAl feAtures The condition affects the sexes equally. The earliest manifestations usually develop in childhood or adolescence but may be delayed until middle or old age. The earliest cutaneous manifestation is sudden diffuse or nodular swellings involving the upper lip, the lower lip and one or both cheeks in decreasing order of frequency [8,26,30]. Labial swelling occurs in about 75% and facial swelling in 50% of patients [31]. Less commonly,the forehead, eyelids or one side of the scalp may be involved. The attacks are sometimes accompanied by fever and mild constitutional symptoms, including headache and even visual disturbance. At the fi rst episode the oedema typically subsides completely in hours or days, but after recurrent attacks the swelling may persist, and slowly increases in degree . It gradually becomes fi rmer and eventually acquires the consistency of firm rubber. After some years, the swelling may very slowly regress.
  34. 34. A fissured or scrotal tongue is seen in 20–40% of cases.It is present from birth in some, which may indicate genetic susceptibility.There may be loss of sense of taste and decreased salivary gland secretion .The 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 intermittentat fi rst, 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 [32]. Involvement of the CNS has also been reported, but the signifi cance of the resulting symptoms is easily overlooked as they are very variable, sometimes simulating disseminated sclerosis but often with a poorly defi ned association of psychotic and neurological features. Autonomic disturbances man occurs
  35. 35. DiagnosisThe essential feature of the syndrome is the granulomatous swelling of lip or face. In the early attacks clinical differentiation from angio-oedema may be impossible in the absence of either scrotal tongue or facial palsy.Persistence of the swelling between attacks should suggest the diagnosis, which can sometimes be confirmed by biopsy.However, the histologicalchanges are not always conspicuous or specific.In established cases, other causes of macrocheilia must be excluded.Ascher’s syndrome associated with blepharochalasia is likely to cause confusion, although the swelling of the lip is caused by redundant salivary tissue and is present from childhood. Lymphoma is a rare differential diagnosis .
  36. 36. treAtments Reactions to dietary components should be sought and possible antigens avoided. The injection of up to 10 mL triamcinolone(10 mg/L) into the lips after local analgesia may be effective . The injections may have to be repeated every 4–6 months once a response plateau has been reached. This treatment has also been successfully combined with surgical reduction (cheiloplasty) . The injections must be continued periodically after the surgery or there may be an exaggerated recurrence of the condition. Surgery alone is relatively unsuccessful Systemic corticosteroids are rarely indicated [44] since adverse effects may be a problem and not all respond [41,45]. Clofazimine appears to help the majority of patients [36,46–48], in a dose of 100 mg twice daily for 10 days, then twice weekly for 4 months. Metronidazole may also produce resolution in granulomatous cheilitis
  37. 37. exfOliAtive cheilitis Exfoliative cheilitis is a chronic superficial infl ammatory disorder of the vermilion borders of the lips characterized by persistent scaling .  The diagnosis is now restricted to those few patients whose lesions cannot be attributed to other causes, such as contact sensitization or light
  38. 38. AetiOlOGYMany cases are now thought to be infactitious, owing to repeated lip sucking, chewing or other manipulation of the lips.There is no association with dermatological or systemic disease, although rare cases are seen in HIV infection, Some are infected with Candida species.
  39. 39. clinicAl feAturesMost cases occur in girls or young women, and the majority have a personality disorder .The process, which often starts in the middle of the lower lip and spreads to involve the whole of the lower or both lips, consists of scaling and crusting,more or less confined to the vermilion border, and persisting in varying severity for months or years. The patient often complains of irritation or burning, and can be observed frequently biting or sucking the lips. In some cases the condition appears to start with chapping or with atopic eczema, and develops into a habitic.In a large Russian series, almost half the cases had associated thyroid disease , but this observation has not been confirmed.
  40. 40. DiAGnOsisContact and active cheilitis must be carefully excluded.Chronic exfoliative cheilitis is readily contaminated by Candida. In such cases the clinical features are variable and may simulate carcinoma, LP or lupus erythematosus.
  41. 41. 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
  42. 42. PlAsmA cell cheilitis
  43. 43. Plasma cell cheilitis is an idiopathic benign inflammatory condition,characterized by dense plasma cell infiltrates in the lips and other mucosae close to body orifices . The condition has been reported (under a wide variety of names) to affect the penis, vulva,lips, buccal mucosa, palate, gingiva, tongue, epiglottis and larynx.Plasma cell cheilitis is the counterpart of Zoon’s plasma cell balanitis . It presents as circumscribed fl at or elevated patches of erythema, usually on the lower lip in an elderly person.The cause is unknown, but it responds to the application of powerful topical corticosteroids such as clobetasol, or to the intradermal injection of triamcinolone , or to systemic griseofulvin A similar lesion, which tends to form a tumorous mass with a hyperkeratotic surface and needs to be differentiated from extramedullary plasmacytoma [8], has been called plasma- acanthoma
  44. 44. Thank you