Sunday, December 13, 2015

Perplexing Recurrent Cheilitis

Presented by Henry Foong
Ipoh, Malaysia
Abstract: A 20-year-old man presented with recurrent cheilitis 

HPI: A 20-year-old student presented with recurrent peeling of the lips for about 3 years. It usually began on the upper lip then involved the lower lip. Then the cycle repeated. The entire process takes about 3 weeks. He has no known drug allergy. He denied any lip smacking. He was using a moisturising non-SLS tooth paste.

Examination showed peeling of the lower and upper lip as a single friable sheet. His oral cavity and genitalia were unremarkable.

Clinical Images

Patch Tests:                                 
Gold sodium thiosulphate  ++ at 48 and 96 hours;
Iodopropynyl butylcarbamate  + at 48 and – at 96 hours
Sodium bisulphide + at 48 and 96 hours
Thimerosal +/- at 48 and 96 hours

Histopathology: The sections show a fragment of tissue surfaced by parakeratinised stratified squamous epithelium. The underlying connective tissue is moderately collagenous with mild chronic inflammatory cells infiltration and a few small blood vessels. A few lobules of minor salivary glands are observed. No granuloma seen in the sections examined. Final Path Diagnosis: Lower labial mucosa: Histologically non-specific 

Diagnosis: Chronic cheilitis

Reason for presentation  
Despite avoiding all the trigger factors such as lip smacking and use of non-SLS toothpaste, his symptoms persisted. The patch test results are probably irrelevant in his case. In a study from Singapore, toothpastes were the commonest cause of allergic contact cheilitis in males. Ricinoleic acid and the patient's own lip preparations were the commonest relevant contact allergens. The absence of granuloma practically make granulomatous cheilitis unlikely.

What is the most likely diagnosis? Could this be a case of exfoliative cheilitis? Exfoliative cheilitis, a rare, localized condition, is a chronic superficial inflammatory condition that is characterized by regular peeling of a superficial excessive layer of keratin. the cause of this condition is unknown but may be associated with depressive illness. Two other differential diagnosis comes to mind - pemphigus vulgaris and Crohn's disease.

1. Mani SA, Shareef BT. Exfoliative cheilitis: report of a case. J Can Dent Assoc. 2007 Sep;73(7):629-32. AbstractFull Free Text.

2. Lim SW, Goh CL. Epidemiology of eczematous cheilitis at a tertiary dermatological referral centre in Singapore.Contact Dermatitis. 2000 Dec;43(6):322-6. Abstract.

3.  Contact allergy in cheilitis.  O'Gorman SM, Torgerson RR.  Int J Dermatol. 2015 Nov 6.  Abstract. (See Dr. Sharquie's comments)

4. Exfoliative Cheilitis DermNet-NZ. (excellent synopsis)

chronic cheilitis, exfoliative cheilitis


  1. From Professor Khalifa Sharquie (Baghdad): I am doing a study on this probably new entity that was not described before. I call it 'chronic loose scaly cheilitis' It is a disease of young adults, both sexes are affected, no history of lips licking and sucking no drugs or chemical are used on lips but this condition has very characteristic clinical picture.The patient usually presents with loose easily detachable thick scaly crust sheets effecting both lips but when removed will leave oozing fleshy red lips.This scaly crusts will be reformed again and the patient has no desire to remove again so sometimes it might be related to so called dermatitis neglecta and here psychological factors could be incriminated. This condition will be published in the next future.

  2. More from Professor Khalifa: "I would like to add more information as I suffered from same problem few months ago and I discovered that chewing gum is the cause of my problem and now every thing is ok when I decided no more chewing.

  3. from Rochelle Trogerson (Mayo Clinic): The photos and the history seem consistent with exfoliative cheilitis. It is a challenging problem and possibly multifactorial. For evaluation I would usually recommend biopsy (done), patch testing (done) and swab for aerobic bacterial and fungal cultures. I would then avoid or treat as results indicate. If left with empiric treatments, I would start with Vaseline from the tub applied frequently throughout the day (and only Vaseline-nothing else). A well-defined trial of topical corticosteroids or topical tacrolimus would be reasonable as well.

  4. Very interesting clinical pictures. I have only seen a similar presentation in patients who were very sick with respiratory conditions and had chronic night mouth breathing. Could the patch test allergy to gold actually have some significance? Is there a topical product being used. I would consider vaniply, paraben and lanolin free ointment 3 times a day and gentle exfoliation of his lips. I agree with making sure that he is not using chewing gum, or any special mouthwashes or alcoholic drinks.


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