Derm Dx: Painful lip swelling, crusting and fissures - Clinical Advisor

Derm Dx: Painful lip swelling, crusting and fissures

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  • Before treatment

    Before treatment

    Before treatment

  • After treatment

A 45-year-old male presents with a six-day history of swelling, crusting and fissuring of the lips. The patient reports significant pain, and says he has been unable to eat.

Prior to the eruption the patient reports he applied lip balm for chapped lips. He has no prior history of herpes labialis, and denies being in contact with individuals with similar eruptions. He is a nonsmoker and works as a physician assistant in cardiology. The physical exam is depicted in the accompanying image; his oral mucosa is clear.

The patient is placed on an oral corticosteroids for 10 days. At the follow-up appointment, his lips are back to normal and the pain, edema and fissuring have resolved (see before and after photos).

Allergic contact cheilitis -- a form of contact dermatitis that occurs on the lips -- is characterized by edema, fissuring, crusting and vesiculation. The lip vermillion border is involved much more frequently than the mucosal lip, and women are affected...

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Allergic contact cheilitis — a form of contact dermatitis that occurs on the lips — is characterized by edema, fissuring, crusting and vesiculation. The lip vermillion border is involved much more frequently than the mucosal lip, and women are affected much more frequently than men, as the majority of cases are attributable to lipstick. 

Other causes of contact cheilitis include, but are not limited to: lip balms, sunscreens, toothpaste, other dental-care products, and nickel, as is found on the mouthpieces of musical instruments. The skin, but not the flesh, of mangoes can also cross react with poison ivy to cause allergic contact cheilitis. 

Diagnosis

A contact cheilitis diagnosis is based on the clinical appearance of edema, crusting, fissuring and vesiculation of the lip vermillion. In this case, the offending agent was suspected to be an ingredient in the lip balm. In order to identify and confirm the causative agent, patients may undergo a special kind of skin allergy testing called patch testing. Patch testing is able to identify a relevant allergen in 25% to 30% of patients with contact cheilitis. 

In this case, the diffuse edema, fissuring and crusting affecting both the upper and lower lip vermillion is consistent with contact cheilitis. Orolabial herpes simplex virus infection usually presents as a recurrent eruption of painful grouped vesicles. The most common location is the cutaneous lip at the junction of the lip vermillion.

Actinic cheilitis is a chronic inflammatory reaction of the lower lip due to chronic exposure to sunlight. The lip becomes scaly, atrophic and occasionally fissured. There is a risk of subsequent transformation to squamous cell carcinoma. Fordyce spots are ectopic sebaceous glands located in the lip. 

Treatment

Treating contact cheilitis consists of advising patients to avoid the suspected offending agents, and prescribing topical steroids or topical calcineurin inhibitors. 

In this case, because the severe and painful nature of the eruption was impeding the patient from eating, he was assigned to a short course of oral corticosteroids, consisting of prednisone 40 mg for five days, which was then tapered to 20 mg for five days.

The patient reported that the eruption completely cleared by the fourth day of therapy. He was advised to discontinue all lip balms and to only use white petrolatum (petroleum jelly), as needed, for his chapped lips.

The patient denied recurrent eruptions at three-month follow-up. However, if he reports a recurrent eruption in the future, and the causative agent cannot be readily identified, we will refer him to a patch-testing specialist for evaluation. 

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine in Houston.

References

  1. Bolognia J, Jorizzo JL, Rapini RP. “Chapter 71 – Oral Disease.” Dermatology. St. Louis, Mo.: Mosby/Elsevier, 2008.
  2. James WD, Berger TG, Elston DM et al. “Chapter 28: Dermal and Subcutaneous Tumors.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.
  3. Freeman S, Stephens R. “Cheilitis: Analysis of 75 cases referred to a contact dermatitis clinic.”Am J Contact Dermat.1999 Dec;10(4):198-200.
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