Friday, January 11, 2013

Cheilitis Challenge

Dr. Yogesh Jain from  presents a dramatic case of cheilitis for your opinion.

He reports: “These lesions have been present for 6 months in this 20 year old woman.
They are rather itchy. On direct questioning she admits to a tendency to lick her lips. She also has some rawness of mouth after eating spices. There are no other systemic symptoms or signs."

Clinical Photo:

He asks "Is this lip lick dermatitis ?

Questions: Do you think this is atopic or allergic contact?  It would be good to know if this woman has a personal or family history of atopy?  If patch testing is difficult because of where she lives, what would be your approach?

Diagnosis:  Cheilitis.  Lick Eczema vs. Allergic Contact Dermatitis

1. Contact allergy in chronic eczematous lip dermatitis. Schena D, Fantuzzi F, Girolomoni G. Eur J Dermatol. 2008 Nov-Dec;18(6):688-92. doi: 10.1684/ejd.2008.0520. Epub 2008 Oct 27.  Email:  Free Full Text Link.
Abstract:  Chronic eczematous cheilitis comprises a heterogeneous group of disorders, the cause of which often remains obscure. Our object was to investigate the frequency of contact allergy in a cohort of patients with chronic eczematous cheilitis attending a tertiary referral clinic. Patients (106 females and 23 males) with chronic eczematous cheilitis were analyzed retrospectively. All patients were tested with a standard patch test series and a fraction with a dedicated patch test series. Children were also tested with atopy patch tests. Moreover, all patients were investigated for past or current presence of atopic diseases. Patch-test reactions of possible or probable relevance were detected in 84 patients (65.1%; 72 females; median age 40), of uncertain or not relevant significance in 26 (20.1%) and negative in 19 (14.7%). An extended series was necessary to reveal hapten hypersensitivity in 42 patients. The most frequent causes of allergic cheilitis were nickel, fragrances, balsam of Peru, chromium salts and manganese salts, present primarily in cosmetics, dental materials and oral hygiene products. Twenty four patients (18 females; median age 21; 18.6%) were diagnosed as having atopic dermatitis of the lips. Four children had allergic contact cheilitis to haptens or food allergens, whereas six had atopic cheilitis. Twenty one cases (16.3%) were considered irritant contact cheilitis. Allergic contact cheilitis is common in adult patients, with the haptens responsible varying with age. Patients with chronic eczematous cheilitis should undergo extended patch testing.

2. Epidemiology of eczematous cheilitis at a tertiary dermatological referral centre in Singapore. Lim SW, Goh CL. Contact Dermatitis. 2000 Dec;43(6):322-6.
Epidemiology of eczematous cheilitis at a tertiary dermatological referral centre in Singapore.
Abstract: In a retrospective epidemiologic study of 202 patients with eczematous cheilitis attending a patch test clinic, females (182 (90%)) predominated over males (20 (10%)). The mean age of our patients was 30.9 years. There was no significant difference between the mean age of females (31 years) presenting with cheilitis compared to males (29 years). Endogenous cheilitis (53%) was the commonest diagnosis, followed by allergic contact dermatitis (34%) and irritant contact dermatitis (5.4%). A personal history of atopy was recorded in 33%. There was no significant difference in the prevalence of atopy between the sexes or among the diagnoses. The mean duration of cheilitis was 16.4 months. The duration was significantly longer in males (29 months) than in females (15 months) (p=0.004). The mean number of positive patch test reaction in patients with allergic contact cheilitis (2.8) was significantly higher than in those with irritant contact cheilitis (0.2) (p = 0.012) or endogenous cheilitis (0.5) (p = 0.00). The commonest cause of allergic contact cheilitis were lip cosmetics, including lipsticks and lipbalms, followed by toothpastes. The commonest cause of irritant contact cheilitis was lip-licking, lipsticks and medication. In 81/202 (40%) patients, 1 or more causes of contact cheilitis could be ascertained. In females, lip cosmetics were the commonest cause, accounting for 54% (44/81) of cases. Toothpastes accounted for 21% (17/81), followed by topical medication 7% (6/81). For males, toothpastes were the commonest cause of allergic contact cheilitis. Ricinoleic acid and the patient's own lip preparations were the commonest relevant contact allergens.


  1. Yes, I agree this looks like lip-lick dermatitis, which typically comes off in winter in children with atopic background.

    However, a possibility of allergic contact dermatitis should be kept in mind.
    Vijay Zawar
    Prof Dermatology

  2. This is either a "lick" eczema or allergic contact dermatitis. I would start by treating with cool compresses and a weak to moderate strength topical steroid ointment -- such as triamcinalone 0.1% b.i.d. after cool compresses for no more that two weeks. If this continues, you may be able to find a centre that does patch testing. Pt. should be counseled, in addition, to try to stop lip licking. You need to determine if there is any psychiatric history as some of these patients can have an OCD-like picture.

    1. In addition I would also consider

      Orificial Tuberculosis in HIV


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