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.
4. 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
5. 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.
6. 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.
7. 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 .
9. Infective cheilitis
Viral:
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.
10. 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
11. 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 .
12. Others:
Red swollen lips with fi ssuring and exfoliation
are prominent in mucocutaneous lymph node
syndrome (Kawasaki disease).
13. 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
14. 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.
15. 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 .
16. 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.
17. 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
18. 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.
19. 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
21. 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
22. 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
23. 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
25. 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
27. 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
28. 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.
29. 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
30. 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
31. Granulomatous
cheilitis:
This is a chronic swelling of the lip due
to granulomatous infl ammation
of unknown cause.
Melkersson in 1928 described labial
oedema in association with recurrent
facial palsy.
Rosenthal in 1930 emphasized the role
of genetic factors and added scrotal
tongue to the syndrome.
The full syndrome has since been
called Melkersson–Rosenthal
syndrome
In Miescher’s cheilitis the
granulomatous changes are confi ned
to the lip, and this is generally regarded
as a mono symptomatic
form of Melkersson–Rosenthal
syndrome, although the possibility
remains that these may be two
separate diseases
32. 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
33. 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
34. 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.
35. 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
36. 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 .
37. 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
38. 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
39.
40. 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.
41. 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.
42. 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.
43. 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
45. 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
