Cheilitis
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aetiology, Causes of cheilitis, Chapping due to cold and wind , Eczematous cheilitis, Contact cheilitis, Drug-induced cheilitis, Infective cheilitis
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Cheilitis
- 1. Tutorial presentation Cheilitis Presenter:- Dr. Pradeep Garg
- 2. • • • • • 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
- 3. Causes of cheilitis. Chapping due to cold and wind Actinic prurigo of the lip Eczematous cheilitis Glandular cheilitis Contact cheilitis Granulomatous cheilitis Drug-induced cheilitis Exfoliative (factitious) cheilitis Infective cheilitis Plasma cell cheilitis Angular cheilitis Nutritional cheilitis Ultraviolet irradiation Dermatoses Actinic cheilitis Trauma
- 4. ‘Chapping’ of the lips • Reaction to adverse environmental conditions • 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
- 5. Eczematous cheilitis • Presenting as redness with dryness, scaling and fissuring. • Major causes- atopic dermatitis and irritant or allergic contact reactions • Treatment- Emollients and topical corticosteroids. • A potent steroid may be required to bring the condition under control
- 6. Contact cheilitis • F>M • 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 groups. • Reactions to food mainly affect children. • Patients are often also atopic.
- 7. • 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
- 8. • C/f- Lipstick cheilitis may confined to the vermilion or extends beyond. • Persistent irritation and scaling or a more acute reaction with oedema and vesiculation. • Other forms of cheilitis vary greatly in their clinical appearance. • 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
- 9. • 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 carried out. • Treatment- Topical corticosteroids will give symptomatic relief but the offending substance must be identified and avoided
- 10. Infective cheilitis • Viral- HSV are common, and VZV and HPV may also affect the lips. • 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.
- 11. • 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.
- 12. • 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 necrosis. • 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 (Kawasaki disease).
- 13. Angular cheilitis Synonym-Angular stomatitis • 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 (marionette lines) • Dry chapped lips • Proliferation of bacteria (impetigo), yeasts (thrush) or virus (cold sores)
- 14. • 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 deficiency • Systemic illness, particularly IBD (ulcerative colitis and Crohn disease) • Sensitive skin, especially atopic dermatitis • Genetic predisposition, for example in Down syndrome • Oral retinoid
- 15. • • • • • • • • • • C/fPainful cracks / fissures Blisters / erosions / ooze / crusting Redness, Bleeding It may progress to more widespread impetigo or candidal skin infection on the adjacent skin and elsewhere. Investigations Culture of swabs taken from the corners of the mouth may reveal: Candida albicans Staphylococcus aureus Herpes simplex
- 17. • • • • • • • • • TreatmentLip balm or thick emollient ointment, applied frequently Topical antiseptics Topical or oral antibiotic Topical antifungal cream Oral antifungal medication Topical steroid ointment Nutritional supplements Filler injections or implants to build up the oral commissures
- 18. Actinic cheilitis • 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 melanocytes.
- 19. • • • • • 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
- 20. Chronic actinic cheilitis with leukoplakia actinic cheilitis
- 21. • 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.
- 22. Glandular cheilitis • Inflammatory changes and swelling of salivary glands in the lips. • 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 be squeezed. • 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.
- 23. • Surface is covered by crusts and scales, beneath which the salivary duct orifices may be discovered. • In the most severe forms there may be deep-seated infection with abscess formation and fistulous tracts. • 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 be required
- 24. Granulomatous cheilitis • 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 lips. • 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.
- 25. • Swelling of the lower lip and one or both cheeks may follow in Melkersson-Rosenthal syndrome. • 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.
- 26. • • • • • 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 dermis.
- 27. Granulomatous cheilitis of the lower lip.
- 28. • 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. • NSAIDS • Mast cell stabilisers eg ketotifen • Clofazimine • Sulfasalazine • Surgical reduction
- 29. Exfoliative cheilitis • Presenting as continuous peeling of the lips. • Factitial- if the behaviour triggering the condition is attention-seeking. • Exfoliative - obsessive-compulsive with no intent of gain. • Mainly affects young adults <30 years with personality disorders. • Initiating factors include: Mouth breathing, Lip licking, Lip sucking, Lip picking, Lip biting. • Poor oral hygiene, HIV infection and Candida.
- 30. • 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 speaking. • Other symptoms include sensations of: Tingling, Itch, Dryness, Ulceration or fissuring may occur
- 31. Factitious cheilitis due to repeated lip sucking
- 33. • 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.
- 34. Plasma cell cheilitis • Uncommon chronic inflammatory dermatitis that presents with flat to slightly elevated erosive erythematous plaques. • Genital areas are often involved, k/a plasma cell balanitis or vulvitis. • Sometimes resistant to conventional topical corticosteroid therapy • Recent reports show that topical calcineurin inhibitors are effective
- 35. Lupus erythematosus • Involvement of the vermilion zone is quite common in both DLE and SLE. • DLE can be premalignant, and should be treated vigorously with topical steroid ointments and sunscreens. • Cheilitis of SLE more severe, with erosions and haemorrhagic crusts. • Lupus erythematosus can be very difficult to distinguish from LP of the lips, both clinically and by histology
- 36. THANK YOU
- 37. • Possible fruit and vegetable allergens. Apple Fennel Asparagus Artichoke Carrot Cherry Orange Peach Pear Lime Parsley Onion Garlic Parsnip Mango Celery Potato Tomato Pineapple Plum Banana
- 38. Miscellaneous objects- Metal hair clips metal pencils cobalt paint on blue pencils nail varnish Wooden nickel and reed mouthpieces of musical instruments
- 39. Lipsticks and lipsalves mineral oils and wax oleyl alcohol castor oil azulene lanolin sesame oil preservatives, stearates perfumes colophony colours eosin azo dyes Sunscreens (e.g. cinnamic aldehyde)
- 40. Mouthwashes and dentrifices, Dental preparations- essential oils imonene peppermint pinene cinnamon phellandrene spearmint linalool carvone alcohol
- 41. • 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. • 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.
- 42. • 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.
- 43. • 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 biopsy. • In established cases, other causes of macrocheilia must be excluded. • Lymphoma is a rare differential diagnosis.
- 44. Actinic prurigo • 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 native Americans. • Treatment- Sunscreens, β-carotene, PUVA, and antihistamines. • Oral thalidomide may be tried