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Chronic loose scaly cheilitis: An often-overlooked variant
Khalifa E. Sharquie
, Robert A. Schwartz, Adil A. Noaimi, Inas K. Sharquie, Sara A Ali
1Department of Dermatology, College of Medicine, University of Baghdad. Iraqi and Arab Board for Dermatology and Venereology, Baghdad Teaching Hospital, Medical City, College of Medicine, Baghdad, Iraq, 2Dermatology, Rutgers New Jersey Medical School, 185 South Orange Avenue, 07103. Newark, NJ, USA, 3Department of Microbiology & Immunology, College of Medicine, University of Baghdad, Baghdad, Iraq, 4Department of Dermatology, Baghdad Teaching Hospital; Medical City, Baghdad, Iraq
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ABSTRACT
Background: Chronic cheilitis is a common dermatological problem where it is caused by many diseases, such as atopic dermatitis, licking dermatitis, and cheilitis simplex. Exfoliative cheilitis is a well described entity where its etiopathogenesis is not well elucidated.
Objective: The objective was to report a new variant of exfoliative cheilitis named chronic loose scaly cheilitis that has new distinctive and descriptive clinical features.
Patients and Methods: This cross-sectional, descriptive study was conducted during the period from 2014 to 2021, in which all patients with chronic loose scaly cheilitis were collected. Full demographic and clinical evaluation was performed. Patients were advised not to use any lipstick, toothpaste drugs, or chemicals on their lips during the course of the study.
Results: Ten patients were fully analyzed. Their ages ranged from 25 to 45 years, with a mean of 32 years, with 6 females and 4 males. The duration of the disease ranged from 3 to 5 years. No history of lips licking or sucking was present, and no drugs, lipsticks, or chemicals were applied to the lips. Also, no history of excessive sun exposure was mentioned. The patients gave a highly characteristic picture as they presented with loose, easily detachable, thick scale crust sheets affecting both lips, but when removed, leaving oozing fleshy red lips with this scaly crust being reformed again shortly. Surprisingly, the patients had no desire to remove it. On examination, all patients showed thick, scaly crusts covering both lips, very loose and easily removed, leaving a bleeding red surface. The oral cavity was normal. The patients’ psychology apparently was normal as no features of anxiety, depression, or psychosis were detected. No personal or family history of atopy or psoriasis was recorded. All types of therapy, including topical emollients, steroid ointment, and tranquilizer, were tried but gave mild relief.
Conclusion: This is a new variant of cheilitis that has a highly distinctive chronic course and a characteristic clinical picture, refractory to therapy, that bears the name chronic loose scaly cheilitis.
Key words: Chronic cheilitis, Exfoliative cheilitis, Chronic loose scaly cheilitis
INTRODUCTION
Cheilitis is an acute or chronic inflammation of the lips. The need to delineate a group of cheilitis was recognized by Sharquie [1], who noted the morphology as a chronic loose scaling cheilitis and suggested a reemphasis based upon the clinical appearance. Usually, it involves the lip vermilion and the vermilion border, but it may affect the surrounding skin, and the oral mucosa may also be affected by inflammatory reactions [2].
Exfoliative cheilitis (EC) is an inflammatory disease affecting the lips and is characterized by the production of a thick keratin scale that is painful and crusted [3]. There is continuous production of desquamated thick, brown scales and crusts of keratin [4,5]. The keratin layer of the epidermis of the lips experiences an accelerated growth and death rate than normal and desquamates [6]. When these scales-crusts are removed, an apparently normal appearing lip is revealed beneath [5]. Although there may be associated erythema and edema, this problem has no well-defined particular cause [3].
In some patients, there is an association with anxiety, depression, stress or personality disorder [3,4]. In one report, 87% of patients had some form of psychiatric disturbances, and 47% had dysfunction of the thyroid, which in turn may induce psychiatric problems such as depression [7]. Some cases, exfoliative cheilitis is thought to represent factitious damage, termed factitious cheilitis or artifactual or cheilitis artefacta [4,5,7,8]. This could be related to repetitive lip licking or pricking habits [3]. This is seen as crusting and ulceration caused by repetitive sucking and chewing of the lips [8]. Some consider habitual lip picking or licking to be a form of a nervous tic [9]. This habit is sometimes termed perleche [4]. Factitious cheilitis is significantly more commonly seen among young females [7,8]. Exfoliative cheilitis has also been linked to HIV/AIDS [7]. Treatment consists commonly of keeping the lips moist and the application of topical corticosteroids ranging from hydrocortisone to clobetasol. There have also been reports of using topical tacrolimus [10]. This may be helpful in some cases, but others require psychotherapy such as tranquillizers or antidepressants [11,12]. In one study, patch testing was conducted and was negative for the common allergens.
It is a general term as there are many well-differentiated types and with variable etiological factors. Cheilitis simplex: also called chapped lips [13,14] or common [15]. Are featured by drying, peeling and fissuring of the lips, and are one of the most common variants of cheilitis [13,16]. The lower lip is commonly involved but it may also affect the upper lip [16]. There may also be the formation of large, painful cracks when these lips are stretched. Lip biting, licking, or rubbing habits are frequently involved in the pathogenesis of this type cheilitis. Paradoxicalbe theinuous licking of the lips induces drying and irritation, and finally, the mucosa splits or cracks and this act, over time, becomes a habit. The lips have a greater tendency to dry out in cold, dry weather. The digestive enzyme present in saliva may also irritate the lips, and evaporation of water in saliva saps moisture from them [17]. Some children have the habit of chewing and sucking on the lower lip, producing a combination of cheilitis and sharply demarcated perioral erythema [18]. Therapy could be successful with barrier lubricants such Vaseline [13]. Medical-grade (USP) lanolin accelerates the repair of the lips [19] and is used in some lip repair products. Some complementary and alternative medicine sources claim that nasal sebum may be a beneficial remedy [14].
Eczematous cheilitis (also termed lip dermatitis [20]): Lip cheilitis is a diverse group of disorders that often have an unknown cause [2]. Chronic eczematous reactions account for most cases of chronic cheilitis. It is divided into endogenous due to an inherent characteristic of the individual, and exogenous where it is caused by an external cause. The main cause of endogenous eczematous cheilitis is atopic cheilitis (atopic dermatitis), and the main causes of exogenous eczematous cheilitis are irritant contact agents inducing allergic contact cheilitis [21]. The latter is characterized by dryness, cracking, edema, and crusting [10]. It affects females more commonly than males, in a ratio of about 9:1 [22]. The most common causes of allergic contact cheilitis is lip cosmetics, including lipsticks and lip balm, followed by toothpaste [22]. An allergy to balsam of Peru can also induce as chronic cheilitis [23]. Allergies to metal, wood, or other component may cause cheilitis reactions in musicians, especially players of wood wind and brass instruments [24], that is, the so called clarinetists cheilitis [25]. Therapy employs an emollient and topical corticosteroids.
Differential Diagnosis
Actinic cheilitis
Actinic cheilitis, also termed solar cheilosis, is a disease that is the result of chronic overexposure to UV light in sunlight radiation. It usually involves the lower lip, causing dry, scaling, and a wrinkled, gray white appearance [22]. It is especially common in people with light skin types who live in sunny climates, and in persons who spend outdoor activities for long periods of time. There is a small risk of this condition going into squamous carcinoma in the long term, yet lip cancer is usually noticed early and, hence, has a good prognosis compared to oral cancer generally.
Angular cheilitis
Angular cheilitis is inflammation of one or both angles of the mouth [9]. It is a fairly common condition, and often affects elderly people associated with infection.
There are numerous possible causes, including nutritional deficiencies such as of iron, zinc, B vitamin, folate, contact allergy, infections such as Candida albicans, Staphylococcus aureus or B-hemolytic streptococci.
Infectious cheilitis
Infectious cheilitis refers to cheilitis caused by an infectious disease [8]. The names bacterial cheilitis [5] and candidal cheilitis [26] are sometimes used to refer to the involvement of Candida organisms and bacterial species, respectively. Herpes labialis is a common cause of infectious cheilitis [8,27,28]. Recurrence of latent herpes simplex infection may cause lesions in the mouth corners and be confused with other causes of angular cheilitis. In fact, this is herpes labialis and is sometimes called angular cheilitis.
Granulomatous cheilitis
Orofacial granulomatosis is the enlargement of both lips due to the formation of a non-caseating granulomatous reaction, which obstructs lymphatic drainage of orofacial soft tissue, causing lymphedema. A related condition is Melkersson–Rosenthal syndrome, a triad of facial palsy, chronic lip edema, and fissured tongue [28]. Meischer’s cheilitis [29], and granulomatous macrocheilitis [30] are synonyms of granulomatous cheilitis.
Drug-induced cheilitis
Common causes of drug-related cheilitis include etretinate, protease inhibitors, indinavir, and isotretinoin [9,31]. Uncommon causes include atorvastatin, clofazimine, busulphan, cyancobalamin, clomipramine, gold methyl dopa, psoralen, streptomycin, and tetracycline [9]. A condition known as “drug-induced ulcer of the lip” is described as ulcerations of the lip without induration [10]. It is induced by the oral administration of drugs, and the condition stops when these drugs are withdrawn [32].
Cheilitis glandularis
Cheilitis glandularis is a rare inflammatory reaction of the minor salivary glands, usually in the lower lip, which appears swollen and everted [10]. There may also be crusting ulceration, abscess, and sinus tracts. It is an acquired disease, yet the cause is not well known [33]. Suspected causes include sunlight, tobacco, poor oral hygiene, syphilis, and genetic factors [7]. The opening of the minor salivary gland ducts becomes inflamed and dilated, and there might be muco-purulent discharge from these ducts. Cheilitis glandularis usually affects middle-aged and elderly males and has the risk of malignant transformation to squamous cell carcinoma (18% to 35%) [7]. Preventive management such as vermilionectomy is, therefore, the therapy of choice [7].
Plasma cell cheilitis
Plasma cell cheilitis is a very rare condition that occurs more on the gingiva and sometimes on the tongue [34]. Plasma cell cheilitis appears as a well-defined, infiltrated, dark red plaque with superficial lacquer-like glazing [10]. Plasma cell cheilitis usually affects the lower lip [34]. The lip looks dry, atrophic, and fissured [7].
Other causes
Thus, the aim of the present work is to assess the new picture of cheilitis that has a distinctive, characteristic clinical course, which makes it different from other types of cheilitis.
PATIENTS AND METHODS
This cross-sectional, descriptive study was conducted during the period from 2014 to 2021 during which all patients with chronic loose scaly cheilitis were collected. Full demographic and clinical evaluation was performed. Psychological assessment was done. All other causes of the cheilitis or cheilitis-like picture were excluded. Also, any history of drug intake related to cheilitis such as retinoids was confirmed. Patients were advised not to use any lipstick, toothpaste drugs, or chemicals on their lips during treatment and follow-up.
RESULTS
Ten cases were seen, 6 females and 4 males, with a ratio of 1.5. Their ages ranged from 25 to 45 years, with a mean of 32 years. They presented with chronic cheilitis of many years duration, which ranged from 3 to 5 years. No history of lip licking or sucking was present, and no drugs, lipsticks, or chemicals were applied to the lips. Also, no history of excessive sun exposure was mentioned. The patients gave a highly characteristic picture that, when seen once, could not be missed again. The patients presented with loose, easily detachable, thick scale crust sheets affecting both lips, which when removed, left oozing fleshy red lips, with this scaly crust being reformed again shortly. Surprisingly, the patients had no desire to remove it, so sometimes, it was suspected and confused with dermatitis neglecta. On examination, all patients showed thick, scaly, wet crusts covering both lips, very loose and easily removed, leaving a bleeding red oozing surface (Figs. 1a – 1d). Full examination of the oral cavity revealed no abnormalities. The patients’ psychology apparently was normal as no features of anxiety, depression, or psychosis were detected. No personal or family history of atopy or psoriasis was recorded.
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Figure 1: (a) A 27-year-old woman with chronic loose scaly cheilitis. (b) A 35-year-old woman with chronic loose scaly cheilitis. (c) A 28-year-old male showing chronic loose scaly cheilitis. (d) A 40-year-old male with chronic loose scaly cheilitis after removing the crust. |
All types of therapy, including topical emollients, steroid ointment, and tranquilizer were tried but all gave temporary and mild relief followed by recurrence.
DISCUSSION
This chronic, loose, scaly cheilitis has some features similar to exfoliative cheilitis but we are not sure that both conditions are the same, although this new variant has a more distinctive and characteristic clinical course that makes it different from other types of cheilitis. Still, the name chronic eczematoid cheilitis could be applied to this variant of cheilitis [6,21].
No features of other skin diseases such as atopic dermatitis, solar cheilitis, lichen planus actinicus, psoriasis were detected in ten cases after a long follow-up. Thus, these patients are unique in their characteristic descriptive features, which deserve the term chronic loose scaly cheilitis.
This condition is usually chronic, and its course takes many years and is refractory to all types of therapy. Although patients are worried about their condition, they have no apparent morbid psychology. The patients have no desire to remove the thick scale crusts on their lips. So, dermatitis neglecta [36] is suspected in some patients. These patients might have some psychological disturbances in the form of depression or anxiety, yet these emotional problems usually appear as a consequence of this chronic, refractory, and annoying condition.
In conclusion, chronic loose scaly cheilitis has highly characteristic descriptive features that deserve to be considered a specific variant of exfoliative cheilitis that needs more attention and research to reach the actual etiopathogenesis.
Statement of Human and Animal Rights
All the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the 2008 revision of the Declaration of Helsinki of 1975.
Statement of Informed Consent
Informed consent for participation in this study was obtained from all patients.
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